Teaching Medical Students How to Write Medicolegal Documents in the EHR

Teaching Medical Students How to Write Medicolegal Documents in the EHR Kathryn Hufmeyer MD Heather Heiman MD Jennifer Bierman MD Division of General Internal Medicine, Department of Medicine Objectives 1. To list current methods from Northwestern and participants institutions for teaching medical students responsible EHR documentation. 2. To describe two interactive learning sessions aimed at improving the quality of trainees EHR-based documentation. 3. To develop strategies for addressing the hidden curriculum in clinical documentation. 4. To discuss challenges in implementing an EHR documentation curriculum at your institution 2

Introductions Audience pair and share: climate of current teaching practices 3 EHR Training and Note Writing Session for Third Year Students

Powerchart Training: navigating, progress note writing, medication reconciliation and more 1. Locate patient information in Powerchart and identify your relationship with the patient. 2. Find necessary flowsheets within Powerchart, including vital signs, 7 day, radiology/studies 3. List the steps of electronic health record medication reconciliation at admission. 4. Define SOAP note and differentiate a SOAP note from an H&P 5. Describe the features of a good progress note 6. Name common errors in progress notes 7. Construct a progress note in the electronic health record. As long as E&M rewards terrible notes and doctors want to be paid, nobody should be surprised that technology has evolved to hit the financial incentives rather than facilitate good clinical care as Chief of Medicine for the 4th largest safety net health care system in the country, I have outlawed cutting and pasting. It is illegal and immoral and bad for both patient care and student/resident education. I have to review many EMR notes to do quality reviews and autopsy reviews, and (especially in the ICU) the notes are unreadable and laughably wrong and stupid. Of course, the faculty, residents, and students have completely ignored my mandate Is more information always better? Do we need every note cluttered with low priority information? Should much of the chart be imported into each note that in the end looks like a crazy quilt ransom note? Is it ok to use 24 characters to convey what could be conveyed in 5? Are physicians who are really good at using smart text and dot phrases, who can rapidly blow in volumes of data into their notes, getting really good at the wrong things?

TRUST : A mnemonic for a quality progress note T R U S T A Trustworthy note is Reasoned Updated Succinct Truthful The Daily Progress Note aka the SOAP note Jennifer Bierman, MD and Heather L. Heiman, MD Division of General Internal Medicine

Objectives and Agenda Objectives 1. Define SOAP note 2. Remember (or refer to) our instructions for writing a good progress note 3. Avoid common errors in progress notes Agenda 1. Presentation of each section of a SOAP note 2. Case 3. Practice note-writing 4. Review 4. Use a mnemonic to check the quality of your progress note Subjective Overnight events May include some medical data; this has become part of the story Patient s current concerns Brief Pertinent to the problems you will assess and manage Discipline Specific Surgery (Incisional pain, flatus, bowel movements.) Psychiatry (groups attended,meals eaten, PRN meds needed)

Example Subjective -No acute events o/n; vomited once this AM -Patient has been NPO after midnight -In pain o/n but now controlled on 2 Norco 325/5's -Wife requested heparin shots be given with lidocaine cream -Patient was quiet again this AM and his wife did all of the talking -This AM states that his symptoms of CP, nausea and SOB are no longer present -IR attending was contacted and stated that tunneled vas cath procedure should be done off of whatever anti-platelet agents cardiology feels are safe to stop Dr. XXX was contacted and stated that he would come see the patient. He said that he would preliminarily recommend NOT stopping the prasugrel or the aspirin given the short time since the stent placement -Temporary vas cath placed today and f/u echo tomorrow - should get echo with definity contrast IV -According to Dr. XXX and cardiology attending - the definity should not cause kidney injury (explained this to the pt) -Dialysis later today -Since admission pt denies fevers, chills, abdominal pain, diarrhea, constipation. - 11 Objective Vitals May be automatically inserted Clean them up! Current physical exam Does not need to be complete Emphasize presence or absence of specific exam findings pertinent to major items on problem list You will find templates

Assessment and Plan Summary statement is helpful with complicated patients Problem by problem Primary concern is first Diagnosis or organ system-based Diagnostic and therapeutic workup Make your clinical reasoning clear Progress should be clear Avoid perjorative language, focus on behaviors Example Assessment and Plan

Common errors: Assessment and Plan No assessment or not your own assessment Most important issue is not first Progress of patient is unclear Too much detail left in once diagnosis is made clear over the hospital course. Especially when students copy and paste previous assessment and plan but do not update Inactive or resolved diagnosis discussed Practice Case 16

Team Taught Session Combining EHR Navigation with Note Writing Session Power Chart Trainers Opening a chart Choosing relationship Navigating flow sheets Entering vitals Resource buttons i.e. EPIC Creating patient lists Viewing orders and medication administration Physician Teachers Medication reconciliation Allergy entry Didactic on writing a progress note Role play rounds Allow creation of a real progress note in test environment Resident coaching 17 Powerchart Training: navigating, progress note writing, medication reconciliation and more 1. Locate patient information in Powerchart and identify your relationship with the patient. 2. Find necessary flowsheets within Powerchart, including vital signs, 7 day, radiology/studies 3. List the steps of electronic health record medication reconciliation at admission. 4. Define SOAP note and differentiate a SOAP note from an H&P 5. Describe the features of a good progress note 6. Name common errors in progress notes 7. Construct a progress note in the electronic health record.

Powerchart Training : learning objectives Learning Objectives 1. Locate patient information in Powerchart and identify your relationship with the patient. (CLQI 3b) 2. Find necessary flowsheets within Powerchart, including vital signs, 7 day, radiology/studies (CLQI 3b) 3. List the steps of electronic health record medication reconciliation at admission. (CLQI 3b) 4. Define SOAP note and differentiate a SOAP note from an H&P (PCMC 5) 5. Describe the features of a good progress note (PCMC 5) 6. Name common errors in progress notes (CLQI 3b) 7. Construct a progress note in the electronic health record.(clqi 3b) 2 ½ hour session 2 ½ hour session 40 students 40 students 3 attendings 3 attendings 2 32 Cerner -3 Cerner Trainers Trainers 2 3 2-3 residents Introduction 10 min Powerchart trainers Resource buttons, patient lists 5 min Powerchart trainers Opening chart, choosing relationship 2 min Powerchart trainers Navigating flowsheets 7 min Powerchart trainers Entering patient vitals 5 min Powerchart trainers EPIC view 1 min Powerchart trainers Problems and diagnoses 3 min Powerchart trainers Medication reconciliation and allergies entry Viewing orders and medication admin record 25 min Video from powerchart trainers, Dr. Hufmeyer 5 min Powerchart trainers Creating Progress Notes-didactic 25 min Dr. Bierman and Heiman with Powerchart trainers Role play of rounds 10 min Students Create a progress note 25 min Students -with coaching Free time for chart navigation 25 min Students -with coaching

Introduction 10 min Powerchart trainers Resource buttons, patient lists 5 min Powerchart trainers Opening chart, choosing relationship 2 min Powerchart trainers Navigating flowsheets 7 min Powerchart trainers Entering patient vitals 5 min Powerchart trainers EPIC view 1 min Powerchart trainers Problems and diagnoses 3 min Powerchart trainers Medication reconciliation and allergies entry Viewing orders and medication admin record 25 min Video from powerchart trainers, Dr. Hufmeyer 5 min Powerchart trainers Creating Progress Notes-didactic 25 min Dr. Bierman and Heiman with Powerchart trainers Role play of rounds 10 min Students Create a progress note 25 min Students -with coaching Free time for chart navigation 25 min Students -with coaching BJ1 Introduction 10 min Powerchart trainers Resource buttons, patient lists 5 min Powerchart trainers Opening chart, choosing relationship 2 min Powerchart trainers Navigating flowsheets 7 min Powerchart trainers Entering patient vitals 5 min Powerchart trainers EPIC view 1 min Powerchart trainers Problems and diagnoses 3 min Powerchart trainers Medication reconciliation and allergies entry Viewing orders and medication admin record 25 min Video from powerchart trainers, Dr. Hufmeyer 5 min Powerchart trainers Creating Progress Notes-didactic 25 min Dr. Bierman and Heiman with Powerchart trainers Role play of rounds 10 min Students Create a progress note 25 min Students -with coaching Free time for chart navigation 25 min Students -with coaching

Slide 22 BJ1 Bierman, Jennifer, 2/16/2017

BJ3 Introduction 10 min Powerchart trainers Resource buttons, patient lists 5 min Powerchart trainers Opening chart, choosing relationship 2 min Powerchart trainers Navigating flowsheets 7 min Powerchart trainers Entering patient vitals 5 min Powerchart trainers EPIC view 1 min Powerchart trainers Problems and diagnoses 3 min Powerchart trainers Medication reconciliation and allergies entry Viewing orders and medication admin record 25 min Video from powerchart trainers, Dr. Hufmeyer 5 min Powerchart trainers Creating Progress Notes-didactic 25 min Dr. Bierman and Heiman with Powerchart trainers Role play of rounds 10 min Students Create a progress note 25 min Students -with coaching Free time for chart navigation 25 min Students -with coaching Interactive Didactic session PROS CONS Live test environment Interactive Student comfort Positive feedback 4.2 on 5 point Likert scale Efficient. I liked the use of a case example and practice writing SOAP note! Coordination with Cerner (IT) trainers Need computer lab Attending and resident time intensive

Slide 23 BJ3 Bierman, Jennifer, 2/16/2017

Structured Data Exercise for Second Year Students 25 What Is Structured Data? Standardized information that is coded for analysis and lives within a particular section of the EHR 1. Demographic information 2. Problem list 3. Medications 4. Allergies 5. Family history 6. Habits such as tobacco and alcohol use 7. Vital signs 8. Diagnoses 9. Orders 10. Lab results 11. Health maintenance such as immunizations, cancer screenings, etc. 26

Entering Structured Data Complimentary to the rich free-text narrative, you also need to document structured data for each patient. Entered as a by many different providers, like a wiki. You should be a steward of the medical record and should update information in the structured fields often. 27 Why is storing structured data important? 1. Data can be located easily 2. Can be updated outside context of an encounter. 3. Health record can offer clinical decision support at the point of care 4. Population health can be promoted 5. Reporting of quality metrics is feasible 6. Directed outreach for research 28

Session Logistics: 1 hour Faculty rotate for questions Bring write up of a hospitalized patient done for the course Use playground version of EHR Create patients with same age and gender as their hospitalized patient Practice entering data from H&P into structured fields using step-by-step guide 29 Session Content 1. Health maintenance 2. Problem list 3. Past medical, past surgical, family, social history 4. Medications 5. Allergies 6. Progress Notes Look at alerts that show up given patient s age/sex Add Enter DM, data HF so or EHR CAD and can identify look again an ICD- at alerts. 10 code. Enter data. Add tobacco and look again at alerts Enter Order meds to and which allergies your patient is allergic Use dot phrases within a note to bring in structured data 30

Mixed Student Evaluations Useful for those with less opportunity to use EHR with their preceptors. Wish it had been earlier Technical glitches for some students (1/16 th of the class) A little disorganized 31 Teaching EHR Documentation In Vivo: The Hidden Curriculum

Copy-Paste Policy Feinberg School of Medicine Policy on the Electronic Medical Record for students: It is never appropriate for a student to copy and paste elements of another person s H&P or patient care note into their own note and portray it as their work. All information, other than structured data elements contained within the medical record (vital signs, lab results, medication records, etc) should reflect the student s ability to gather and present patient data. If a student copies and pastes their own note from a previous day, it should reflect all relevant changes in the patient s condition and progression in their understanding/analysis of the patient s underlying disease process. Inappropriate copying and pasting of another person s work will be considered a transgression of the student code of conduct and a professionalism form may be submitted to the Dean s office What Students Think No. responding agree or strongly agree /No. responding (%) It is acceptable to copy and paste from my own previous notes 98/118 (83%) It is acceptable to copy and paste the following part of my own previous note into my note: HPI and review of systems 75/119 (62%) Physical or mental status exam 44/119 (36%) Lab data/radiographic study results 103/119 (87%) Assessment & plan 81/119 (68%) 34

What Students Think No. responding agree or strongly agree /No. responding (%) It is acceptable to copy and paste from other providers notes 12/119 (10%) It is acceptable to copy and paste the following parts of another provider s note into my note: History of present illness 8/119 (7%) Lab data/radiographic study results 66/119 (55%) Assessment & plan 2/119 (2%) I felt comfortable documenting under my attending s name 47/80 (59%) I felt comfortable documenting under my resident s name 31/66 (47%) 35 What Students Do # responding sometimes or more / # answering item I copy elements of my own previous notes 113/119 (95%) I copy elements of residents notes 26/119 (22%) I copy elements of attendings notes 15/119 (13%) I copy elements of other students notes 2/119 (2%) I use auto inserted data for vital signs 117/119 (98%) I use templates for the entire note 100/118 (85%) I use templates for the physical or mental status exam 98/118 (83%) Frequency of documenting while signed in under an attending s name 51/119 (43%) Frequency of documenting while signed in under a resident s name 28/119 (23%) 36

What Students Observe I have witnessed # responding sometimes or more / # answering item Residents copying & pasting elements of another provider's note 102/119 (86%) Attendings copying & pasting elements of another provider's note 70/116 (60%) Students copying & pasting elements of another provider's note 70/119 (59%) 37 I think the copy and paste function is almost vital to writing notes. I personally found that it helped my efficiency and allowed me to be more thorough on each note. I was always careful to go through the text and update it. 38

I like to copy and paste my previous day's note as a template for writing notes. It helps me remember exactly what I was thinking yesterday and how I am changing that for the following day. It is a very efficient way of writing notes, helps me not to forget things and gives me more time to read on my patients conditions. 39 Honestly - read some residents or attendings notes. It is obvious that the ROS or physical exam documented did not occur. From a student's perspective this is confusing and disheartening. 40

Services being consulted on patients tend to copy and paste a lot, so if the primary team or the resident who wrote the first H&P got something wrong, it gets perpetuated because no one cares to confirm it. Most of the time it is the student who notices this mistake but they are not heard until a resident writes a note, even if the correct information was in the student's first note. 41 Hidden Curriculum: A Culture of Documentation Must target whole team Must consider all perspectives Legal Quality/Compliance Resident educators

Communication Medical History Legal Document Planning of Care Provider Billing Hospital Billing Quality Measures Research Data Charlotta Weaver, MD, Northwestern Medicine CPT codes Physician Work RVUs Notes Hospital Charges National Rankings EDW Data ICD 9/ICD 10 Codes Quality Measures Charlotta Weaver, MD, Northwestern Medicine 44

Shared Objectives of Good Note- Writing Copy-paste should be judiciously used Problem-based assessment/plan Problems are assigned diagnoses or differentials Accompanied by clinical reasoning Associated with brief, concise, and updated plan Status of condition is commented upon (mild/severe, improving/persistent/worsening) Consistent Internally (within the note) Externally (among different providers) How do quality and regulatory goals support good note-writing? A thoughtful, synthesized, specific, and updated assessment and plan is: Good for patient care Good from a medical-legal perspective Good for meeting quality goals and meeting regulatory guidelines Good for education

A curriculum in EHR documentation: Where to start? Progress notes are not frequently evaluated In contrast to initial H&Ps and oral presentations Progress notes have large opportunity for errors perpetuated day-to-day 47 EHR Progress Notes Potential pitfalls of EHR progress notes Often duplicative May be outdated May be dishonest (e.g. documenting a PE/ROS that was not performed) Largely computer-generated, full of templated and auto-inserted data Clinical reasoning is omitted or hidden Patient s current condition is unclear New problems/allergies may never make it into a central repository 48

Checklist Development 2011: Our group of attendings from medicine, pediatrics, and psychiatry (and one medical student) began to develop a dichotomous checklist to assess in-patient progress notes Refined based on: Survey of current third year medical students CDIM, SGIM and CGEA National Meeting Workshops Focus groups of attending physicians Input from key hospital administrators Physician director of quality documentation Chief information officer for hospital Risk management Modifications made over 3+ years Checklist Use Evaluator should review 2 days of notes including one from Day 3 or later Does not require knowledge of patient May require some initial training to familiarize with the key, but after that, should only take 5-7 minutes

Subjective The note contains: No Yes N/A 1. Current patient concerns or symptoms. Objective The physical examination contains the No Yes N/A following: 2. Succinct vitals. 3. Examination of all systems relevant to today s positive symptoms. 4. Examination different from previous day s exam. The data portion of the note contains: No Yes N/A 5. Labs only if they are new. 6. Reports of studies only if it is the first day they are included. Mark on scale as defined in key* 0 1 2 N/A 7. A summary or impression of study reports. Assessment and Plan The assessment and plan meets these criteria: No Yes N/A 8. A summary statement is included. 9. The summary statement is different from previous day s statement. 10. Positive symptom(s) from subjective section are included. 11. A problem based assessment is included. Mark on scale as defined in key* 0 1 2 N/A 12. The status of each problem is described. 13. Lab abnormalities are interpreted. 14. Interpretation of studies is included. 15. Problems are written as diagnoses or accompanied by differentials. 16. Active problems are accompanied by clinical reasoning. 17. Problems are associated with brief, clear plans. 18. Assessment and plan is different from previous day s A/P.

Potential Uses Informal curriculum/didactic for inpatient ward attendings Formal curriculum to be performed at the clerkship or medical school level 53 Challenges 54

Thank you Jennifer.Bierman@nm.org khufmeyer@northwestern.edu h-heiman@northwestern.edu 55