Last week, I spoke with a chief medical information officer (CMIO) of a large academic medical center who is embarking on a documentation overhaul. Rather, the CMIO is attempting to embark on a documentation overhaul. It seems that sometimes – and this may be shocking to some of you – we physicians cannot get out of our own way.
One would imagine that rank-and-file doctors would be cheering that someone is trying to improve the often-senseless progress notes that we routinely read and write today. I am picturing the CMIO being placed on their fellow physicians’ shoulders and paraded around the hospital with confetti tossed in the air amid cries of “Hip hip, hooray!” Yet, no such luck.
In the United States, clinical progress notes are nearly four times longer than in other countries. Does that mean four times better for patients and their physicians? No. Studies generally do not show that we are moving in the right direction regarding health outcomes. Further, clinician burnout is rising, and the time spent documenting in the electronic health record (EHR) is a big contributor. So why are physician leaders facing opposition when trying to improve the documentation process? Competing needs between the reader and the author is a major reason that doctors struggle to agree on what entails a good progress note. When we are “consuming” a progress note, physicians are generally looking for the gist of the matter written using the fewest words needed. Most of the time, the gist is the assessment and plan: what’s going on with this patient (the assessment) and what do you intend to do about it (the plan). The assessment and plan are very difficult to template because computers are not very good at understanding what doctors find important and why. If you want an assessment and plan that is all killer, no filler, it often must be written from scratch.
The writer of a progress note often has different priorities. They frequently want to get lots of information into the note to document every data point that informs their care. For these purposes, the EHR is a godsend because it makes it easy (perhaps too easy) to bring hundreds of laboratory and imaging results directly into the progress note. Copy and paste also make it trivial to insert paragraphs of other physicians’ thoughts and recommendations into a note to capture what consultants were thinking at a given point in time. All of this reminds me of the quote sometimes ascribed to Mark Twain: “I didn’t have time to write a short a letter, so I wrote a long one instead.” As a progress note author, EHR technology has made it easy to put everything (including the kitchen sink) into the note, and it is far easier and faster to do that instead of taking the time to write a more concise note with solely relevant information.
Before the letters start coming in from physicians upset that I am calling them lazy, let me say this: I am not calling you lazy – at least most of you! I acknowledge that for decades, we have been taught that if it is not documented, it never happened. We have been on the receiving end of hundreds of hours of lectures about the review of systems and how many body systems we must describe in the physical exam to reach a given level of service for billing purposes. We know colleagues who have been put in the proverbial penalty box for documentation infractions, and we do not want to join them.
Yet, things have changed, and many of us are not keeping up with the times. Starting in 2021, new guidelines have drastically reduced many of the most onerous requirements (thank you, AMA!). Yet many physicians seem incapable of writing the progress notes they authored in the pre-EHR days. Are they not aware of these changes? Are they stuck in their old ways? Are the risk and compliance folks trying to pretend these updates never happened? I am not sure, but many doctors push back against leaders trying to move the dial on documentation.
Another reason for pushback on note updates is the potential divide between the needs of an attending physician and a trainee. In academic medical centers, medical students, interns, residents, and fellows have special requirements that a practicing physician may not share. Doctors in training often need to write longer notes because they are not yet aware of what is most important or how to communicate essential recommendations in brief, actionable language. Hence, they have no options except to pile into their note everything that could be potentially relevant.
Further, physician trainees often use the daily progress note on rounds as their source of truth when presenting to their seniors. When the attending physician asks what the hemoglobin was yesterday or what the ejection fraction was on the echocardiogram completed earlier in the week, the person presenting the case doesn’t want to have to look it up. Hence, if everything that might reasonably be needed on rounds is in every daily progress note, morning rounds will be smoother. I expect this is not the case in hospitals with no trainees, but in academic medical centers, notes that are authored by residents should be expected to be much longer.
What is my advice to the physician leader trying to decrease the documentation burden for their clinicians? Just do it! I think some of us (perhaps most of us) will need to be steered kicking and screaming into a future that, remarkably, will look a bit like the past. Change is difficult, even if it is the change we have been seeking for a long time.