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Leveraging systems thinking to design patient-centered clinical documentation systems
International Journal of Medical Informatics (2005) 74, 395—398
Leveraging systems thinking to design patient-centered clinical documentation systems Adam S. Rothschild a, Linda Dietrich b, Marion J. Ball b,c,∗, Heidi Wurtz b, Holly Farish-Hunt b, Nhora Cortes-Comerer b a
Department of Biomedical Informatics, Columbia University, New York, NY, USA Healthlink Incorporated, Houston, TX, USA c Johns Hopkins School of Nursing, 5706 Coley Court, Baltimore, MD 21210, USA b
Received 29 June 2004 ; received in revised form 23 March 2005; accepted 23 March 2005 KEYWORDS Clinical documentation; Computerized patient record; Electronic health record; Nursing documentation; Problem-oriented medical record
Summary A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. The failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. This paper seeks to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. It also addresses how rethinking clinical documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication. © 2005 Elsevier Ireland Ltd. All rights reserved.
According to Ackoff, a system is a set of interrelated elements, with each element connected to every other element directly or indirectly [1]. A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. We believe that this failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. We suggest that rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication. * Corresponding author. Tel.: +1 410 433 7110; fax: +1 410 433 6314. E-mail address: [email protected] (M.J. Ball). URL: www.healthlinkinc.com.
Hospitals have traditionally purchased IT primarily to support profitable healthcare delivery programs. They have focused on financial and stand-alone departmental systems that are not well-integrated into the hospital’s overall healthcare information infrastructure. These systems may improve the hospital’s short-term profits, but they fail to support the best patient care overall. As we are entering the “decade of healthcare IT”, declared by National Coordinator for Health Information Technology, David Brailer focus is shifting to connect disparate clinical computer systems both within hospitals and across communities. Connecting systems and sharing data is necessary to provide the best patient care, but it is not sufficient. Rather, clinical IT and human systems must coevolve, such that the IT not only supports clinicians in
1386-5056/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2005.03.011
396 their current tasks but actually helps to foster a paradigm of healthcare delivery that is more patient-centered, efficient, and communicative. Quinn describes organizations as having small units that connect the core competencies of an enterprise to the customers of that enterprise [2]. Godfrey and co-workers have applied Quinn’s description of the small unit to healthcare, dubbing it a clinical microsystem [3]. A clinical microsystem is a small group of people who work together to provide care to a subpopulation of patients. The clinical microsystem also includes the people who receive care, not just the care providers. Healthy clinical microsystems have goals, connected processes, a shared information milieu, and they produce measurable outcomes of their services. Microsystems are rooted in larger care organizations. Clinical documentation, ordering of diagnostic and therapeutic measures, and patientrelated communication are called macroprocesses [4]. Macroprocesses cross multiple microsystems within an organization. These processes are reactive to poorly functioning microsystems. Without a shared information milieu, medical errors and inefficiency occur at greater frequency. In this paper, we seek to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. We also seek to address how rethinking clinical documentation and IT together might improve the entire healthcare process by promoting a more integrated and patientcentered healthcare information paradigm
1. Clinical documentation practices reflect and reinforce the fragmented state Healthcare documentation is a fragmented macroprocess. Many data are redundantly recorded by disparate care providers. Each provider documents his findings, which the subsequent providers often do not even read. Some redundancy is necessary for the sake of education; however, we wonder whether already recorded information might be more efficiently reused. Rather than having every clinician ‘‘reinvent the wheel,’’ subsequent clinicians might simply review, edit, update, or annotate previously recorded information. An example of redundancy occurs with the Kardex, which is a nursing document that is one of the most reliable synopses of the patient’s condition and management plan (e.g., current medications, pending labs, etc.). Kardexes are typically maintained by the ward clerk. They are often con-
A.S. Rothschild et al. sulted by physicians, who copy information onto note cards that they can carry with them in their pockets. Even the Kardex itself is redundant since most of the information contained therein actually originates with orders, which themselves are recorded elsewhere and are, in fact, usually placed by the physicians who are copying information from the Kardex. In fact, the Kardex is primarily just an unofficial copy of the patient’s care plan, although it is consulted much more frequently. Similar situations also occur with nurse-recorded vital signs and fluid intake and output (I/O), where physicians copy down these data onto unofficial documents that they use for their daily work, only later copying the data into the official progress notes. All of this redundant recording of information reflects the fragmentation of care across clinical microsystems. Poorly interacting clinical microsystems lead to inefficient macroprocesses and suboptimal patient care. From a different viewpoint, we suggest that the fragmented high-level organization and storage of clinical information also reflects the fragmented state of healthcare. In paper patient charts, physicians’ notes, regardless of the service, are usually stored in the same section of the patient’s chart, but narrative nursing documents are frequently stored in a separate section. We maintain that juxtaposition does not constitute true integration. Although the primary physician frequently summarizes other care providers’ notes in his notes, we maintain that summarization also does not constitute true integration. Many of the objective data recorded by nurses are widely utilized by physicians. These include vital signs, I/O, and the medication administration record (MAR). Nonetheless, they are usually not recorded in the patient’s main chart at the time of collection. Instead, vital signs and I/O flow sheets are usually kept on bedside charts. These charts sometimes accompany nurses to their morning shift change, regardless of the simultaneous need for this information by physicians for their morning rounds. The most current MAR page accompanies the medication cart as it travels from room to room, also making it difficult for the time-pressured physician difficult to find. These examples illustrate how workflow that is driven solely by caregiver convenience leads to fragmented care. The larger system, which results from the interaction between the nurse’s microsystem and the physician’s microsystem, suffers as a result of this fragmentation, as does the patient. It is easy to see how appropriate use of IT can solve these types of problems. Paper is the major artifact that prevents defragmentation of clinical documentation. With paper,
Leveraging systems thinking to design patient-centered clinical documentation systems it is not possible to record information in one view and display it in another view. It cannot be visually reshuffled or logically reused by different healthcare providers or for different purposes without manual copying. With a paper-based system, clinicians lack a compelling reason to meaningfully improve their current documentation practices, but thoughtfully designed IT can change the documentation paradigm by enabling information reuse and differential display. There is wide consensus that computers and digital media should replace pen and paper in healthcare [5—7]. Although this digital transformation is necessary in order to eliminate fragmentation in healthcare, it is not sufficient. Porting paper-based documentation practices to computers simply increases clinical document availability and legibility. Without rethinking the underlying information contained in these documents, this leads to only marginally improved clinical macroprocesses. The notion of ‘‘documents’’ is necessary in healthcare, yet we should change our primary focus to the information contained therein and how it can be most effectively and efficiently recorded and utilized. Documents are merely views of information. The exactly same information can be arranged in different ways to yield different documents. IT is the tool that allows us to consider information independent of the medium upon which that information is recorded. It allows us to automatically display information for different purposes rather than manually copying it and to easily reuse information for other purposes. IT gives us the freedom to create an interdisciplinary system of healthcare information flow that eliminates fragmentation and encourages patient-centered care.
2. An IT-enabled patient-centered clinical documentation paradigm: the problem-driven health record In its current state, clinical documentation by disparate care providers is fragmented, as we have mentioned above. Even so, some have made efforts towards more patient-centric care through creation of computerized multidisciplinary problem lists [8]. This is a big step in the right direction, but we suggest that a stand-alone problem list, even if multidisciplinary, is not enough. As Weed pointed out more than 30 years ago with the introduction of the problem-oriented medical record (POMR), the patient’s problems should serve as the logical threads by which to explicitly organize clinical documentation [9].
397
Our approach, called the problem-driven health record (PDHR), is similar to the POMR in that the problem list also plays a central role. It is different, however, in three major ways. First, the PDHR paradigm is not nearly as strict as the POMR paradigm. In the strict POMR, a separate progress note in the subjective—objective-assessment-plan (SOAP) format is written for each problem, and information that is relevant to more than one problem is recorded redundantly. The PDHR does not require this redundant recording of information. Second, the PDHR is designed specifically to be implemented in an EHR rather than on paper. It is designed to integrate other (traditionally distinct) EHR activities, such as order entry and results review, into the documentation process. Third, it utilizes a controlled medical terminology (CMT) with which to record problems. Using a CMT enables easy downstream reuse of problem data for many purposes such as triggering problem-specific decision support rules and aiding in reimbursement, research, operations management, and public health reporting. The basic idea of the PDHR is that when interacting with a fully functional EHR (i.e., one that performs documentation, order entry, results reporting, etc.), the clinician first enters the patient’s relevant problems and subsequently performs other actions in the explicit context of the single mostrelevant problem to which they relate. The problem thus drives the care. This is true both for order entry [10] and for problem-oriented components of documentation such as assessment and plan sections of progress notes but not for subjective and objective sections of progress notes. This is similar to how clinicians currently document care [11]. Explicitly linking orders to their single most-relevant problems is what provides the logical thread by which to automatically organize test results and operational information such as medication administration record and radiology scheduling. Problem-oriented threading would allow for quick and easily longitudinal tracking of a problem. An interdisciplinary problem-oriented view would keep all providers focused on the whole patient and defragment clinical care. As we have learned from the wise Max Planck, as he responded to his acceptance of the Nobel Prize in physics, ‘‘In the correct formulation of the question, lies the key to the answer.’’ This paper brings to bear that we are finally beginning to ask the right questions, and that, indeed, as is well illustrated in this discussion, successful transformation of clinical documentation will occur when we begin to view the hospital from a systems-oriented perspective. This is a lesson well postulated by Ackoff [12].
398
A.S. Rothschild et al.
References [1] R.L. Ackoff, Ackoff’s Best: His Classic Writings on Management, John Wiley and Sons Inc., New York, 1999. [2] J.B. Quinn, Intelligent Enterprise: A Knowledge and Service Based Paradigm for Industry, The Free Press, New York, 1992. [3] E. Nelson, P. Batalden, M. Godfrey, L. Headrick, T. Huber, J. Mohr, J. Wasson, Clinical Microsystem Action Guide: Improving Healthcare by Improving Your Microsystem, version 2.1, Trustees of Dartmouth College, 2004. [4] D. Galloway, Mapping Work Processes, American Society for Quality, Milwaukee, WI, 1994. [5] Institute of Medicine (U.S.), Committee on Improving the Patient Record, in: D.E. Detmer, E.B. Steen, R.S. Dick (Eds.), The Computer-Based Patient Record: an Essential Technology for Healthcare, revised ed., National Academy Press, Washington, D.C., 1997. [6] Institute of Medicine (U.S.), Committee on Quality of Healthcare in America, Crossing the Quality Chasm: a New
[7] [8] [9] [10]
[11]
[12]
Health System for the 21st Century, National Academy Press, Washington, D.C., 2001. L.T. Kohn, J. Corrigan, M.S. Donaldson, To Err is Human: Building a Safer Health System, National Academy Press, Washington, D.C., 2000. J.R. Campbell, Strategies for problem list implementation in a complex clinical enterprise, Proc. AMIA Symp. (1998) 285—289. L.L. Weed, Medical records that guide and teach, N. Engl. J. Med. 12 (1968) 593—600, 652—657. A.S. Rothschild, H.P. Lehmann, Information retrieval performance of probabilistically generated, problem-specific CPOE pick-lists: a pilot study, J. Am. Med. Inform. Assoc. (e-pub ahead of print), Jan 31, 2005, doi:10.1197/jamia.M1670, available at http://www.jamia.org. H. Takeda, What has changed after Dr. Lawrence Weed’s paper in 1968? in: J.H. Van Bemmel, A.T. McCray (Eds.), Yearbook of Medical Informatics: The Promise of Medical Informatics, Schattauer, Stuttgart, 1999. R.L. Ackoff. Op cit.
Leveraging systems thinking to design patient-centered clinical documentation systems Adam S. Rothschild a, Linda Dietrich b, Marion J. Ball b,c,∗, Heidi Wurtz b, Holly Farish-Hunt b, Nhora Cortes-Comerer b a
Department of Biomedical Informatics, Columbia University, New York, NY, USA Healthlink Incorporated, Houston, TX, USA c Johns Hopkins School of Nursing, 5706 Coley Court, Baltimore, MD 21210, USA b
Received 29 June 2004 ; received in revised form 23 March 2005; accepted 23 March 2005 KEYWORDS Clinical documentation; Computerized patient record; Electronic health record; Nursing documentation; Problem-oriented medical record
Summary A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. The failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. This paper seeks to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. It also addresses how rethinking clinical documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication. © 2005 Elsevier Ireland Ltd. All rights reserved.
According to Ackoff, a system is a set of interrelated elements, with each element connected to every other element directly or indirectly [1]. A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. We believe that this failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. We suggest that rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication. * Corresponding author. Tel.: +1 410 433 7110; fax: +1 410 433 6314. E-mail address: [email protected] (M.J. Ball). URL: www.healthlinkinc.com.
Hospitals have traditionally purchased IT primarily to support profitable healthcare delivery programs. They have focused on financial and stand-alone departmental systems that are not well-integrated into the hospital’s overall healthcare information infrastructure. These systems may improve the hospital’s short-term profits, but they fail to support the best patient care overall. As we are entering the “decade of healthcare IT”, declared by National Coordinator for Health Information Technology, David Brailer focus is shifting to connect disparate clinical computer systems both within hospitals and across communities. Connecting systems and sharing data is necessary to provide the best patient care, but it is not sufficient. Rather, clinical IT and human systems must coevolve, such that the IT not only supports clinicians in
1386-5056/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2005.03.011
396 their current tasks but actually helps to foster a paradigm of healthcare delivery that is more patient-centered, efficient, and communicative. Quinn describes organizations as having small units that connect the core competencies of an enterprise to the customers of that enterprise [2]. Godfrey and co-workers have applied Quinn’s description of the small unit to healthcare, dubbing it a clinical microsystem [3]. A clinical microsystem is a small group of people who work together to provide care to a subpopulation of patients. The clinical microsystem also includes the people who receive care, not just the care providers. Healthy clinical microsystems have goals, connected processes, a shared information milieu, and they produce measurable outcomes of their services. Microsystems are rooted in larger care organizations. Clinical documentation, ordering of diagnostic and therapeutic measures, and patientrelated communication are called macroprocesses [4]. Macroprocesses cross multiple microsystems within an organization. These processes are reactive to poorly functioning microsystems. Without a shared information milieu, medical errors and inefficiency occur at greater frequency. In this paper, we seek to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. We also seek to address how rethinking clinical documentation and IT together might improve the entire healthcare process by promoting a more integrated and patientcentered healthcare information paradigm
1. Clinical documentation practices reflect and reinforce the fragmented state Healthcare documentation is a fragmented macroprocess. Many data are redundantly recorded by disparate care providers. Each provider documents his findings, which the subsequent providers often do not even read. Some redundancy is necessary for the sake of education; however, we wonder whether already recorded information might be more efficiently reused. Rather than having every clinician ‘‘reinvent the wheel,’’ subsequent clinicians might simply review, edit, update, or annotate previously recorded information. An example of redundancy occurs with the Kardex, which is a nursing document that is one of the most reliable synopses of the patient’s condition and management plan (e.g., current medications, pending labs, etc.). Kardexes are typically maintained by the ward clerk. They are often con-
A.S. Rothschild et al. sulted by physicians, who copy information onto note cards that they can carry with them in their pockets. Even the Kardex itself is redundant since most of the information contained therein actually originates with orders, which themselves are recorded elsewhere and are, in fact, usually placed by the physicians who are copying information from the Kardex. In fact, the Kardex is primarily just an unofficial copy of the patient’s care plan, although it is consulted much more frequently. Similar situations also occur with nurse-recorded vital signs and fluid intake and output (I/O), where physicians copy down these data onto unofficial documents that they use for their daily work, only later copying the data into the official progress notes. All of this redundant recording of information reflects the fragmentation of care across clinical microsystems. Poorly interacting clinical microsystems lead to inefficient macroprocesses and suboptimal patient care. From a different viewpoint, we suggest that the fragmented high-level organization and storage of clinical information also reflects the fragmented state of healthcare. In paper patient charts, physicians’ notes, regardless of the service, are usually stored in the same section of the patient’s chart, but narrative nursing documents are frequently stored in a separate section. We maintain that juxtaposition does not constitute true integration. Although the primary physician frequently summarizes other care providers’ notes in his notes, we maintain that summarization also does not constitute true integration. Many of the objective data recorded by nurses are widely utilized by physicians. These include vital signs, I/O, and the medication administration record (MAR). Nonetheless, they are usually not recorded in the patient’s main chart at the time of collection. Instead, vital signs and I/O flow sheets are usually kept on bedside charts. These charts sometimes accompany nurses to their morning shift change, regardless of the simultaneous need for this information by physicians for their morning rounds. The most current MAR page accompanies the medication cart as it travels from room to room, also making it difficult for the time-pressured physician difficult to find. These examples illustrate how workflow that is driven solely by caregiver convenience leads to fragmented care. The larger system, which results from the interaction between the nurse’s microsystem and the physician’s microsystem, suffers as a result of this fragmentation, as does the patient. It is easy to see how appropriate use of IT can solve these types of problems. Paper is the major artifact that prevents defragmentation of clinical documentation. With paper,
Leveraging systems thinking to design patient-centered clinical documentation systems it is not possible to record information in one view and display it in another view. It cannot be visually reshuffled or logically reused by different healthcare providers or for different purposes without manual copying. With a paper-based system, clinicians lack a compelling reason to meaningfully improve their current documentation practices, but thoughtfully designed IT can change the documentation paradigm by enabling information reuse and differential display. There is wide consensus that computers and digital media should replace pen and paper in healthcare [5—7]. Although this digital transformation is necessary in order to eliminate fragmentation in healthcare, it is not sufficient. Porting paper-based documentation practices to computers simply increases clinical document availability and legibility. Without rethinking the underlying information contained in these documents, this leads to only marginally improved clinical macroprocesses. The notion of ‘‘documents’’ is necessary in healthcare, yet we should change our primary focus to the information contained therein and how it can be most effectively and efficiently recorded and utilized. Documents are merely views of information. The exactly same information can be arranged in different ways to yield different documents. IT is the tool that allows us to consider information independent of the medium upon which that information is recorded. It allows us to automatically display information for different purposes rather than manually copying it and to easily reuse information for other purposes. IT gives us the freedom to create an interdisciplinary system of healthcare information flow that eliminates fragmentation and encourages patient-centered care.
2. An IT-enabled patient-centered clinical documentation paradigm: the problem-driven health record In its current state, clinical documentation by disparate care providers is fragmented, as we have mentioned above. Even so, some have made efforts towards more patient-centric care through creation of computerized multidisciplinary problem lists [8]. This is a big step in the right direction, but we suggest that a stand-alone problem list, even if multidisciplinary, is not enough. As Weed pointed out more than 30 years ago with the introduction of the problem-oriented medical record (POMR), the patient’s problems should serve as the logical threads by which to explicitly organize clinical documentation [9].
397
Our approach, called the problem-driven health record (PDHR), is similar to the POMR in that the problem list also plays a central role. It is different, however, in three major ways. First, the PDHR paradigm is not nearly as strict as the POMR paradigm. In the strict POMR, a separate progress note in the subjective—objective-assessment-plan (SOAP) format is written for each problem, and information that is relevant to more than one problem is recorded redundantly. The PDHR does not require this redundant recording of information. Second, the PDHR is designed specifically to be implemented in an EHR rather than on paper. It is designed to integrate other (traditionally distinct) EHR activities, such as order entry and results review, into the documentation process. Third, it utilizes a controlled medical terminology (CMT) with which to record problems. Using a CMT enables easy downstream reuse of problem data for many purposes such as triggering problem-specific decision support rules and aiding in reimbursement, research, operations management, and public health reporting. The basic idea of the PDHR is that when interacting with a fully functional EHR (i.e., one that performs documentation, order entry, results reporting, etc.), the clinician first enters the patient’s relevant problems and subsequently performs other actions in the explicit context of the single mostrelevant problem to which they relate. The problem thus drives the care. This is true both for order entry [10] and for problem-oriented components of documentation such as assessment and plan sections of progress notes but not for subjective and objective sections of progress notes. This is similar to how clinicians currently document care [11]. Explicitly linking orders to their single most-relevant problems is what provides the logical thread by which to automatically organize test results and operational information such as medication administration record and radiology scheduling. Problem-oriented threading would allow for quick and easily longitudinal tracking of a problem. An interdisciplinary problem-oriented view would keep all providers focused on the whole patient and defragment clinical care. As we have learned from the wise Max Planck, as he responded to his acceptance of the Nobel Prize in physics, ‘‘In the correct formulation of the question, lies the key to the answer.’’ This paper brings to bear that we are finally beginning to ask the right questions, and that, indeed, as is well illustrated in this discussion, successful transformation of clinical documentation will occur when we begin to view the hospital from a systems-oriented perspective. This is a lesson well postulated by Ackoff [12].
398
A.S. Rothschild et al.
References [1] R.L. Ackoff, Ackoff’s Best: His Classic Writings on Management, John Wiley and Sons Inc., New York, 1999. [2] J.B. Quinn, Intelligent Enterprise: A Knowledge and Service Based Paradigm for Industry, The Free Press, New York, 1992. [3] E. Nelson, P. Batalden, M. Godfrey, L. Headrick, T. Huber, J. Mohr, J. Wasson, Clinical Microsystem Action Guide: Improving Healthcare by Improving Your Microsystem, version 2.1, Trustees of Dartmouth College, 2004. [4] D. Galloway, Mapping Work Processes, American Society for Quality, Milwaukee, WI, 1994. [5] Institute of Medicine (U.S.), Committee on Improving the Patient Record, in: D.E. Detmer, E.B. Steen, R.S. Dick (Eds.), The Computer-Based Patient Record: an Essential Technology for Healthcare, revised ed., National Academy Press, Washington, D.C., 1997. [6] Institute of Medicine (U.S.), Committee on Quality of Healthcare in America, Crossing the Quality Chasm: a New
[7] [8] [9] [10]
[11]
[12]
Health System for the 21st Century, National Academy Press, Washington, D.C., 2001. L.T. Kohn, J. Corrigan, M.S. Donaldson, To Err is Human: Building a Safer Health System, National Academy Press, Washington, D.C., 2000. J.R. Campbell, Strategies for problem list implementation in a complex clinical enterprise, Proc. AMIA Symp. (1998) 285—289. L.L. Weed, Medical records that guide and teach, N. Engl. J. Med. 12 (1968) 593—600, 652—657. A.S. Rothschild, H.P. Lehmann, Information retrieval performance of probabilistically generated, problem-specific CPOE pick-lists: a pilot study, J. Am. Med. Inform. Assoc. (e-pub ahead of print), Jan 31, 2005, doi:10.1197/jamia.M1670, available at http://www.jamia.org. H. Takeda, What has changed after Dr. Lawrence Weed’s paper in 1968? in: J.H. Van Bemmel, A.T. McCray (Eds.), Yearbook of Medical Informatics: The Promise of Medical Informatics, Schattauer, Stuttgart, 1999. R.L. Ackoff. Op cit.