Transcript Design Principles for Physician Documentation

Design Principles for
Physician Documentation
in Electronic Health Records
Eric Rose, MD
Clinical Assistant Professor, Department of Family
Medicine and Division of Biomedical and Health
Informatics, University of Washington
Physician Consultant, IDX Systems Corporation
http://faculty.washington.edu/momus/infodoc.htm
OUTLINE
 Overview of physician documentation
– Definition
– Purpose(s)
– Common structural conventions
 Review of modalities for electronic physician
documentation
 The three dimensions of documentation tool
effectiveness
 Questions for discussion
May 29, 2005
Eric Rose, M.D.
Overview of Physician
Documentation
 Definition—?
Patient-specific information
Generated by a physician
Capable of being viewed as text
 “Physician’s Note” = the viewable endproduct
May 29, 2005
Eric Rose, M.D.
Overview of Physician
Documentation
 Purpose(s)—?
Inform subsequent care
Inform current care (“writing-as-thinking”)
Research
Legal purposes
Billing purposes
Drive automated processes, e.g. “decisionsupport” (electronic-structured only)
May 29, 2005
Eric Rose, M.D.
Why Should Documentation be
User-Centric?
The Physician’s Note is…
First and foremost…
A STORY
May 29, 2005
Eric Rose, M.D.
Overview of Physician
Documentation
Common Structural Conventions for the
Physician’s Note
– The “SOAP” note (cf. Weed 1968)
– The “H & P” note
– The ICU note
– The Therapeutic Procedure note
– The Diagnostic Procedure note
May 29, 2005
Eric Rose, M.D.
The “SOAP” note
SUBJECTIVE: Mr. Gringoire is a 50-year-old gentleman who returns to clinic for followup of COPD. He
continues to smoke approximately one pack a day. His shortness of breath is somewhat improved on
Advair. There has been no other significant change to his symptoms since his last visit. His present
medication regimen consists of Advair 500/50 one puff BID and Combivent MDI PRN.
OBJECTIVE:
GENERAL: Well-appearing male.
VITAL SIGNS: BP 110/71, Wt 63.2 kg, HR 82, Temp 96.8, O2 sat 95% on RA
HEAD AND NECK: Clear. There is no lymphadenopathy.
CHEST: Clear to auscultation bilaterally. His expiratory phase is prolonged but there are no wheezes.
ASSESSMENT: In summary, this is a 50-year-old gentleman with severe COPD who continues to smoke. I
once again strongly stressed to him the absolute essential need for him to stop smoking as this is the only
meaningful thing that will improve his pulmonary health. I have prescribed him Wellbutrin and he will
plan on enrolling in a smoking cessation class per his health plan. Otherwise, he will continue to treat his
COPD with Advair metered dose inhaler.
PLAN:
1. Smoking cessation.
2. Continue Advair.
3. Pulmonary rehabilitation.
4. Consider leukotriene antagonist next meeting.
5. No current need for supplemental oxygen.
6. The patient will return to clinic in three months. Additionally, I again recommended considering a cardiac
evaluation including a stress test to evaluate his mild chest discomfort as he has numerous risk factors for
CAD.
May 29,
2005
Eric Rose, M.D.
The “H & P” note
IDENTIFYING DATA: The patient is a 40 year old male admitted for left lower leg cellulitis.
HISTORY OF THE PRESENT ILLNESS: The patient presented to the Family Medicine clinic today stating
that he was in his usual state of good health until about 5 days ago when he noticed pain and redness on
the lateral aspect of his left lower leg. He had had an abrasion there from about 1 week previously …
PAST MEDICAL HISTORY: The patient has moderate persistent asthma well-controlled on his current
regimen (see below); no other significant PMHx. He has no known history of malignancy or
thrombophilia.
PAST SURGICAL HISTORY: None
FAMILY MEDICAL HISTORY: His parents are both living and in good health…
CURRENT MEDICATIONS: Advair 100/50 1 puff BID; Proventil MDI PRN
ALLERGIES: No known drug allergies
SOCIAL HISTORY: The patient owns a used bookstore, is married, and has one teenage son. He drinks
approximately one alcoholic beverage per week, and denies use of tobacco or illicit drugs.
REVIEW OF SYSTEMS...
PHYSICIAL EXAM…
ASSESSMENT…
May 29, 2005
PLAN…
Eric Rose, M.D.
Other Note Types
(See handouts)
May 29, 2005
Eric Rose, M.D.
Entry Modalities for Electronic
Physician Documentation




Free Text (typed or dictated)
Fixed pre-composed text (“macros”)
Multiple-choice Entry (various UI widgets)
Direct importation from database
Note—All modalities except free-text enable capture of
structured data as by-product of the documentation
process.
May 29, 2005
Eric Rose, M.D.
The three dimensions of
documentation tool effectiveness


Ease of note creation
Data quality of the note
– How much of the relevant information which
was obtained in the physician-patient
encounter ends up in the note
– How accurate the information in the note is
– How richly imbued with meta-data it is (i.e.
how much discrete data collection occurs)

Presentation quality of the note
May 29, 2005
Eric Rose, M.D.
Discussion Questions
 How would YOU design a physician
documentation module for an EHR?
 What are some of the design pitfalls for such a
function?
 How would you design tools for building precomposed documents (“templates”)?
 Should an EHR have one toolset for physician
documentation and another for other users, or
should the toolset be the same across user types?
May 29, 2005
Eric Rose, M.D.
Discussion Questions
 Can EHR-based physician documentation
improve patient safety? How would you
achieve that in your design?
 How should physician documentation tools
be integrated with other EHR functions?
 What difficulties might exist in sharing
documentation templates across separate
organizations using the same EHR
application?
May 29, 2005
Eric Rose, M.D.
Discussion Questions
 If you were implementing an EHR, how
would you approach deployment of
physician documentation functionality (and
template design tools)?
 What challenges or pitfalls might you
anticipate in such deployment?
May 29, 2005
Eric Rose, M.D.
Because physician notes tell a story, they are
usually entirely or in part time-centric…
“Mr. Jones was feeling well until about ten days ago when he
experienced the onset of a dull, bifrontal headache. Over
the following days, the headache steadily worsened and
also seemed to become focused over the left parietal area;
at the same time, he noticed the onset of a dry cough.
About 2 days ago the headache started to diminish, but the
cough worsened and became productive of yellowish
sputum. Yesterday he noticed the onset of fever and flecks
of blood in his sputum, and decided to call for an
appointment.”
What are the implications of this when it comes
to designing physician documentation tools?
May 29, 2005
Eric Rose, M.D.