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Nov 6 2012   1:31PM GMT

Physician documentation: UPMC’s new electronic standardization revolution

Posted by: Jenny Laurello
Children's Hospital of Pittsburgh, CPOE, EHR, MU, physician documentation, University of Pittsburgh Medical Center, UPMC, Workflow

In terms of provider organizations leading the way in integrative, patient centric IT implementation, the University of Pittsburgh Medical Center (UPMC) never fails to impress me. I say this not only as a longtime admirer of the system, but also as a direct observer to the great strides being taken. After two days touring the facilities — meeting with key leaders of the IT strategy and clinical informatics teams — it’s clear UPMC is not only talking the the IT talk, but walking the IT walk.

UPMC is no stranger to electronic health record (EHR) system development. The system was an early adopter of computerized physician-order entry (CPOE) in 2005, and implemented EHRs at its three largest hospital sites between 2006 and 2007. When the HITECH Act was introduced in 2009 and meaningful use (MU) became a reality, UPMC went into hyper drive, bringing five sites online within a year, successfully, in order to meet stage one requirements.

Dr. Vivek Reddy, CMIO of UPMC

Dr. Vivek Reddy

Today, the system is almost completely paperless. And while MU has created what Dr. Vivek Reddy, chief medical information officer for hospital and physician services, referred to as “guardrails for standardization,” there were still barriers to adoption in the beginning including the handling of legacy systems, clinical workflows assessment and user resistance.

And UPMC has come a long way since its early adoption phase: The majority of their campuses achieved HIMSS stage 6 recognition and UPMC’s Children’s Hospital of Pittsburgh reached the coveted stage 7. But there is still a big nut left to crack around physician documentation, which Reddy and his partner in crime, Dr. G. Daniel Martich, chief medical information officer and vice president of physician services for UPMC, are working hard to tackle.

“In MU stage 1, people weren’t really worried about physician documentation,” Reddy noted. “And as different as CPOE was from paper-based documenting, it is relatively limited. But with physician documentation, it needs to be simple, it needs to be succinct and it needs to be easy to enter, read and digest.”

In addition MU requirements, patient encounter data is now directly, electronically tied to reimbursements. How a clinician enters information also stands to be impacted by ICD-10 and having nearly ten times as many codes through which to drill. The ways physicians currently document encounters are as varied as the physicians themselves, which is not conducive to ensuring data is captured in the same way all the time. UPMC is working on projects that it hopes will help doctors enter information using more structured methods.

As Reddy mentioned, “in the world of copy and paste, things are going to get missed, not get coded accurately, which means the data will not be extracted correctly. And while voice recognition and natural language processing (NLP) are great, these are only tools. The lack of standardization and ‘guardrails’ on how docs enter information is, in a sense, playing a ‘degrees of freedom’ game, which is going to have to change.”

Reddy also explained that “we’ve lost our way in terms of documentation. It’s not even clear why we document some things anymore — we simply document everything. And then you get a seven-page record note, which brings up a whole new kind of illegibility issue: data overload. We’ve turned paper to electronic, but not smartly. The unintended consequence of electronic records is that you make the wrong thing to do a very easy thing to do. We need to do a bit more work, but slowly, that will evolve.”

So how does one standardize these “degrees of freedom” in physician documentation? Martich believes you first need to create a structure and set of best practices.

Dr. G. Daniel Martich

Dr. G. Daniel Martich

“We’re looking at our electronic templates and figuring out how we can set parameters around a note’s structure and what data is pulled. We need to go through service line by service line and create the right data mix,” Martich said. “We need less data, as well as to figure out what data is absolutely critical, and change the note format significantly so that nothing gets missed.”

Part of this will be an evolution, and part will be a revolution, Reddy added, so long as it is a collaborative, iterative process. “Because this is so cultural in nature, if we do this in an iterative fashion, and slowly revolutionize, it will become an evolution.”

The other piece of the story, so often lost in the electronic compliance whirlwind, is utilizing technology to improve outcomes, care coordination, and deliver a better, safer, patient experience — all agenda items on which Reddy and Martich are intensely focused.

“We need to make sure patients have access to a readable story. The main goal of a record is to convey what’s going on with a patient so we can track and deliver care. Communication in general is the biggest reason for errors — we need to fix this,” Martich believes.

And with MU stage 2, patient transparency is a critical component. “As physicians, we use unusual abbreviations and tend to speak in code. But the second that something becomes transparent (to a patient), you suddenly become very aware of what you document,” Reddy noted.

Martich agreed, adding that with increased transparency, and as patients get more involved and interact with their records more and more, we will see a marked shift in how electronic information is communicated between physicians and patients. He then referenced the recently concluded OpenNotes study, a year-long trial in which 105 doctors shared their notes with 19,000 patients throughout participating hospital systems in Boston, Pennsylvania and Seattle. While nearly all patient participants (99%) elected to continue using OpenNotes after the study concluded, there remained a significant difference between what patients and physicians felt they should be able to control and edit within the record.

Disagreement in data editing abilities aside, there was no disconnect between Reddy and Martich in wanting to reconcile data overload in patient records and shift the current mentality behind physician documentation.  As Martich noted, “this is one example of patients — at the center — being the driving force of change. This shift starts to redefine the patient / physician conversation, and a lot of us are going to get a wakeup call.”

Jenny Laurello is senior community manager for the Health IT Exchange,’s dedicated networking and community portal. Be sure to follow Jenny on Twitter @HITExchange and @jennylaurello.

Questions? Comments? Please leave them here below or ask Reddy and Martich directly on our Q&A forum!

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