Folks - our role as CMIOs is often to serve as the bridge between real-world clinicians and pie-in-the-sky (or at least non-clinically oriented) legal/admin/executives/IT/politicians, etc… And one of our chief responsibilities is thus to bring everyone back to common sense when hysteria starts to set in.
So please, everyone take a breath - and repeat, "If I am asked to review plagiarism software for my organization, I will tell them they are off their freakin' rocker"… and make them write it down 100 times. Or maybe I will make a deal, if we use it on medical records, then we can also use it on all their legal documents, managed care contracts, annual reports, etc... again, let's just use common sense! We are supposed to be using standardized format and structure… so it is expected that notes should be 60-90% similar from visit to visit, or day to day in the hospital. On the other hand, I know it can get bad - especially on the inpatient side, especially in an AMC where residents, students, fellows and attending are all writing notes!
So what can we do? Telling docs to not use a key functionality doesn't make sense and is very much the "bad apple" approach of punishing everyone because a few abuse the system. We need to think about big picture innovations we can do to improve the system for everyone. I think there are two core issues we need to figure out:
(1) Multiple authors: For this issue, I'd suggest rethinking how notes are created, and consider a multi-contributed note… similar to a Wiki, but would need to meet the legal standards. I believe some EMR vendors are exploring the concept of a multi-contributed note, and I do think there is some balance here in making it both easy to use and higher quality than what we currently do… which is often like a mid-1990s version of MS Word.
(2) Poorly trained providers: I'd put this issue on all of us (GME, Informatics, Clinicians)… I think we have not done nearly as good a job as we should in understanding how to document and then explaining that to those we teach. And we certainly have not made them feel very responsible. I think one way to "monitor/measure" this would be to have random chart audits looking for these type of issues, and present them in an "Morbidity & Mortality" style format that will make providers take documentation a bit more seriously… hmm, I actually like that idea! I hope someone does this and will let me know what happens!
Full text of the original blog: