Monday, February 4, 2013

EMR Wannabe - Part 3



Here is an extract from a rather spirit-lifting brainstorm on the future of clinical documentation, recently published in Healthcare IT News. It envisions the following ceasefire to “chart wars”:

“Imagine the following -- the entire care team jointly authors a daily note for each patient using a novel application inspired by Wikipedia editing and Facebook communication. Data is captured using disease specific templates to ensure appropriate quality indicators are recorded. At the end of each day, the primary physician responsible for the patient's care signs the note on behalf of the care team and the note is locked. Gone are the "chart wars", redundant statements, and miscommunication among team members. As the note is signed, key concepts described in the note are codified in SNOMED-CT. The SNOMED-CT concepts are reduced to a selection of suggested ICD-10 billing codes. A rules engine reports back to the clinician where additional detail is needed to justify each ICD-10 code i.e. a fracture must have the specifics of right/left, distal/proximal, open/closed, simple/comminuted. 

First things first, I am glad to hear that SNOWMED and ICD-10 are now able to interact freely  like good old buddies. That just made my day.

More good news: here comes the multi-authoring concept, which I tend to cherish dearly. But shouldn’t the same happy rule apply to signature? Isn’t signature multiple in essence, especially in teaching hospitals?

Shouldn’t Frank the Resident be able to choose his staff physician as the next signer of a report so the system routes the request for their review upon completion?

And what about the other nagging scenario a.k.a “rollover”? Frank the Resident starts a note and moves on to something more urgent, but the note gets stuck in the queue. No one can access it. Wouldn’t it be good if the system was able to “move” the note to the attending after a predefined time frame? And if the assigned attending hasn't signed it within yet another predefined time frame, wouldn’t it be neat if the system opened it for other staff members to take over?

OK, this is nice, but the above scenarios entail clear protocols and workflows to be established per department beforehand. Yes they do. Because that’s a must, a milestone, a step that can’t be overlooked.

But would this be enough to make “Chart Wars” history? Good question. Maybe a couple of additional light sabers are required to properly support resident and attending Jedis, such as:

·        Over the Shoulder Signature - Frank The Resident presents his note to the attending and they can both sign it off together at the same time - no need for the attending to login in with their own credentials.

·        Oooops Feature – provides a predefined timeframe within which the signer should be able to modify his/her note before it is locked. That would eliminate the whole addendum crap.

·        Multi-level Signature - allows for more than two signatures when required – and often required it is.

·        Add-My-Two-Cents Feature - staff members are trainers, so allowing for comments and track changes might prove helpful to simplify the training workflow.

Here were my two cents on signature. If you can think of more features, please feel free to comment!


1 comment:

  1. How about signing of different parts but different people (nurses vs physiotherapists vs MDs etc)
    What about pieces of info that are necessary for some but should not be displayed or shared with everyone - the standard example her has always been HIV but there are others (mental health info for example)

    How do you reconcile conflicting info at the point of care and subsequently when there is a problem and someone made ad decision on data that was there but then changed?

    The principle is similar to Facebook Medical Record