MD Charting: Physician Documentation Strategies
Ronald M. Ireland
Concordia University – Portland
An Action Research Report Presented to
The Graduate Program in Partial Fulfillment of the Requirements
For the Degree of Masters in Education
For the research question, “Will higher level EHR use help a physician complete high quality patient records in a thorough, medically and legally sound, timely and efficient manner?” numerous articles were reviewed. This literature review appears adequate to suggest appropriate action research. Electronic health records (EHR), becoming universal, ease the tasks of support clinic workers, but substantially increase healthcare provider workload. This increased time commitment is appropriate if associated with an increase in quality outcomes. EHR use can be, but is not necessarily associated with quality care. Physician EHR champions have been shown to positively impact peer use of EHR. Post EHR implementation training has a potential to improve documentation.
Research Literature Review
Medical Records: The Problem
Canadian physicians see a large volume of patients, especially if located rurally. Over 20% of the Canadian population lives in rural areas (communities with less than 10,000 people). However, less than 12% of physicians work in these rural sites (Krupa & Chan, 2005). Keeping up with documentation, while maximizing access, can be a challenge. Patient flow and access could be improved by a more timely completion of patient records. The challenge of course is to retain high quality patient interaction, or even improve it, while also creating records of high quality.
Physicians are trained to efficiently document their work. They are trained in clinical work to summarize pertinent information to a more senior physician in a very short verbal “vignette” often characterized by the term, “a bullet”.
As an example, the medical student, after a long interview of a patient, verbally presents to his staff physician, “48 year old Hispanic widower; alcoholic. Cogent historian. Fatigued, dyspneic. No family in attendance or aware that he’s here. Diabetic, poorly controlled. No meds. Ascites, jaundice, no pronator drift, no tremor. Glycosylated hemoglobin: 0.96. Elevated transaminases. Not coping at home.”
Chart notes are traditionally done by hand. Students are initially taught to handwrite a long several page history, with demographic data, social history, past health, medications, allergies, physical exam, a summary of pertinent labs, a synthesizing statement, and problem formulation followed by a plan of action. With practice, it gets shorter and to the point, but always linear. Thus, both in verbal and written communication, physicians are taught to report in a concise narrative format (Han & Lopp, 2013).
Crisp handwriting unravels under the pressure of fast paced lectures. Soon these handwritten summaries are illegible, full of short cuts, short forms, and deletions.
Electronic Health Records (EHR): The answer?
Dictated notes in a hospital setting are of course legible, narrative, and have been around for decades. The use of electronic health records (EHR) in the clinic setting has brought legibility to the clinic. EHR for clinic use is still however far from ubiquitous; in 2011, 54% of all physicians in the U.S. were reported to be using such a system (Jamoom , Beatty & Bercovitz, 2011). Use is increasing quickly. In 2012, 69% of U.S. physicians were using EHR. Canadian statistics show an increase from 37% in 2009, to 56% in 2012 (Schoen, Osborn, Squires, Doty, Rasmussen, Pierson, & Applebaum, 2012). EHR is widely touted as the savior of quality, and a tool for efficiency. Such are the clear claims of EHR suppliers.
Many, if not all, EHR’s support the traditional style of narrative notes. However it is perhaps a safe statement to assume that fewer older physicians excel at typing or have computer expertise. Younger physicians were significantly higher users of EHR than physicians over the age of 50 (Jamoom et al, 2011). Perhaps to partly address this issue, this researcher has found that EHR providers have supplied a list of templates that can be used to document encounters. Templates have a defined structure, in essence a series of fill in the blanks, or click and insert type options.
Templates have advantages apart from ease of data entry (Hann & Lopp, 2013). Many templates are built based on current best practice guidelines. There are physician reminders built in. The use of a template can also aid analysis of medical information. A physician could do a study on his own practice, looking at goals for diabetes, for example: how much of the patient population has seen an optometrist or achieved blood goals? The information held in a template is “more findable” by the computer for analysis. This kind of documentation, however, can be fragmented, and stored in different areas of the chart (Hann & Lopp, 2013).
Physicians simply aren’t trained to read charts presented in such a fashion. In 2009, only 64% of U.S. medical schools allowed students access and use of the EHR (Han & Lopp, 2013). EHR training programs tend to focus on documentation skills, not reading and processing skills.
In essence, therefore, we have an over-burdened specialized workforce confronted with often mandated new technology for health records, largely unable to efficiently document patient interactions in the way they have been traditionally taught. Many physicians engage this new technology in a traditional way, attempting to continue narrative documentation, and miss the advantages of the electronic health record. More time is being spent in documentation with little apparent gain in quality of patient care, apart from chart legibility. Although fully 69% of U.S. physicians in 2012 used EMR, only 27% of them used them at a higher level of functionality. In Canada, the statistics are worse: 10 % used the higher level (Schoen, 2012).
Documentation technique and its reflection on the clinic, clinicians, and patients, will be examined in an attempt to address the research question, “Will higher level EHR use help a physician complete high quality patient records in a thorough, medically and legally sound, timely and efficient manner?”
Medical Record Documentation in Family Practice
Clinic workflow and physician documentation
Multiple factors come into play when addressing completion of records. In the days of paper records, charts had to be pulled (taken from the shelf), topped up with paper, be date stamped, and then taken to the room with the patient (Howard, Clark, Friedman, Crosson, Pellerano, Crabtree, Karsh, Jaen, Bell & Cohen, 2013). Frequently, another family member in the room would also need to be seen. That file would then be called for, by telephone in the exam room, or by the physician going out to get it himself. Lab reports would come in on paper, then be sorted and filed. There was often a delay due to misfiling, or the chart was simply not found. All of this is gone with EHR. Labs are downloaded automatically, and go right on the chart. Physicians have access to results almost as soon as the lab has them (Howard et al, 2013).
Clinic workflow is eased with instant messaging, a feature on most EHR’s. Messages can be sent to the entire staff, or privately to one staff member. Charts can be “locked” to restrict access. Secretaries need access to confidential patient charts: residual paper reports must be scanned in for example, or legal letters prepared formally. The EHR allows the physician or office manager to track who accessed the chart and what was seen: this is a wonderful security feature. So, charts that were once locked in a physician’s desk are now at their fingertips (Howard et al, 2013).
There seems general consensus that EHR has eased clinic clerical work (Howard et al, 2012; Jamoom et al, 2011; Chen, Garrido, Chock, Okawa & Liang, 2009).
Templates: the controversy.
Younger, and more internet/ computer savvy physicians tend to use templates more widely, and with a greater frequency. Studies have shown that their ability to read and make sense of the fragmented data is simply better (Han & Lopp, 2013).
Overall, physicians prefer narrative reports (Han & Lopp, 2013). This is in spite of the great potential of template use. Templates, an interface that stands between the data and the record, mediate the documentation of the clinical interaction. In so doing, the clinician is prompted to remember certain maneuvers, or questions. Information stored in a template is easily accessed for analysis using the EHR, unlike in a narrative note. Unfortunately, the data is often strewn about the computer screen with an apparent lack of cohesion. It’s simply hard to make sense of, especially when trained to write, read, and speak narratively (Han & Lopp, 2013). Physicians also find that the template tends to drive the interaction (Blakeman, Chew-Graham, Reeves, Rogers & Bower, 2011). Questions are asked in order so that boxes can be checked off.
Templates simply do affect the physician-patient dynamic. The tone of the interview, and the substance of the interaction, swing from patient driven concerns to the strict medical model, where the physician is in control, and asks what he feels to be the correct direct questions. Concern is that template use feeds this style, disempowering the patient and formalizes the relationship, pushing the two apart (Blakeman et al, 2011).
Only 38% of physicians reported being “very satisfied” with their EHR. Moreover, fully one quarter of physician respondents did not feel that their EHR improved patient care (Jamoom et al, 2011). However, quality of patient care can be a goal, or it can be a defined and measured outcome. Quality measurements are largely facilitated by template use and subsequent analysis of patient databases. Quality, once measured, moves out of the clouds and becomes a tangible target. Simply put, computers allow automatic measurement of defined parameters. Templates easily allow the gathering of information to meet ministry standards. Not all templates however, even those financially supported by the health ministry, are useful. A qualitative Australian study suggested that template use for the management of chronic disease only helped with billing preventative claims, and did little to support quality of care (Bolger-Harris, Schattner & Saunders, 2008).
When discussing issues of quality, one must consider the patient perspective, not just the scientific view. Surveys have shown that interactions between caregivers and their patients dominated by template use are generally less satisfactory (Blakeman et al, 2011).
Healthcare quality standards have been developed and are in use in many countries, including the U.K., Canada, Australia, the Netherlands, and the U.S. However, in these countries, physicians do not receive routine data on clinical outcomes: in the U.S., 47% of doctors got these updates, whereas only 23% of Canadian providers received them. The highest was the U.K., at 84% (Schoen, Osborn, Squires, Doty, Rasmussen, Pierson & Applebaum, 2012). Payments to physicians in these countries are at least partially related to achieving high standards. Summary quality measurements in the US (i.e. “SQUID” measurements) have shown across the board improvement of approximately 2-3% per year in attainment of goals (Nietert, Wessel, Jenkins, Feifer, Nemeth & Ornstein, 2007). The use of the diabetes arm of the “SQUID” resulted in over a 7% improvement per year (Ornstein, Nietert, Jenkins, Wessell, Nemeth, Feifer & Corley, 2007). There is some data that the use of a payment schedule to attain quality goals correlates with change of practice. Recent development of such a system in Spain showed nothing less than a dramatic increase in central, important indicators of performance compared to before use of this system: vaccination rates (up 24%); lipid control in cerebrovascular disease (up 230%), in ischemic heart disease (up 147%); use of proven drug modalities in heart failure up over 30%. These robust changes occurred in the span of 3 years (Coma, Ferran, Méndez, Iglesias, Fina & Medina, 2013).
There is concern, of course, that development of quality indicators and an associated alteration of a pay schedule to promote their use can lead to inappropriate treatment and patient deletion from one’s practice (Coma et al, 2013). Monetary inducement of physicians to attain quality standards may or may not work: a Cochrane review was inconclusive, citing overall, poorly done studies (Scott, Sivey, Ait Ouakrim, Willenberg, Naccarella, Furler & Young, 2011).
Physicians typically find that the introduction of EHR adds 1-2 hours of work to the typical day. Often, there is work to be done at home (Howard, et al, 2013). Interventions to increase physician productivity are typically front end: EHR training is typically done at the introduction of the system. However, there can be substantial gains in productivity, efficiency, and in physician “life” satisfaction with a peer led review of the use of the EHR system years after introduction (Dastagir, Chin, McNamara, Poteraj, Battaglini & Alstot, 2012).
Rural users of EHR in Alberta had less access to special help than their urban, often hospital based counterparts, and were not able to introduce their EHR systems slowly. Inferences were made that the ability to have access to networks of physicians, more technical support, and better training would outweigh the benefit of financial support for EHR (Ludwick, Manca & Doucette, 2010), sure sign of a struggle with adoption of this documentation method.
Introduction of a system wide EHR led to a dramatic shift in style of patient presentation in Hawaii. Here, clinic visits dropped by over 25%, whereas secure electronic interactions increased almost exponentially. In this system, physicians reported more efficiency, and less visits to achieve goals. Overall patient access to physicians increased 8% (Chen et al, 2009).
The inference here is that non-traditional patient assessments, by email or telephone, could replace at least some more time consuming face-to-face clinic visits. Referrals to secondary sources dropped over 50% (Chen et al, 2009). One could conjecture that earlier, speedier access decreased the occurrence of severe events.
A study in Alberta, Canada looking at urban and rural practices suggested that the use of EHR did not affect patient access (Ludwick, 2010), however innovative techniques such as secure email access were not investigated. EHR was introduced without this capacity for a possible change in the method by which patients could access health care. In 2012 it was reported that only 11% of Canadian practices allowed patients to email a medical question, compared to 34% in the U.S. The highest was Switzerland at 68% (Schoen et al, 2012).
Several facts, or conclusions can be drawn related to documentation strategies for a community physician. The use of EHR is well established and here to stay. Whereas a significant number of American medical schools did not allow student access to the electronic record in 2009 (Han & Lopp, 2013), the majority did. The majority of graduating physicians are acquainted with the EHR. Younger physicians, raised in the computer age with a smartphone in their hands, can navigate these systems quicker and easier than older, established physicians. Not only is documentation easier for these physicians, but also their ability to read and make sense of fragmented data presentation on a computer is higher (Dastagir et al, 2012).
This is today’s wave. The future is now. Templates, the use of which many physicians resist, and is in many ways in contradiction to traditional methods of documentation, can facilitate the delivery of quality of care. More patients have a potential to get better: sometimes a lot more (Nietert et al, 2007; Coma et al, 2013).
There seems to be a price to be paid, in terms of both patient satisfaction, and in total physician time spent. Engaging the patient in a traditional manner, and then attending to the demands of the template appears to be the “best” way of providing holistic, quality care. One might question if there is just time in the day…
It could be suggested, however, that time spent going this extra mile could prevent emergency situations, thereby possibly becoming time neutral, or even time saving. Filling in templates is certainly not urgent. However, it facilitates practice research, quality improvement projects, and more complete situation analysis of that patient interaction. Time management theorists, most notably Covey (1989), stress the importance of spending time in non-urgent, important work. Ensuring that the ischemic heart disease patient is doing all possible disease modifying strategies will lead to less chest pains occurring, less emergent situations that make one drop everything and run.
It appears that EHR takes more time. Records certainly can be of higher quality. The associated templates have a potential, but by no means the guarantee, to improve quality of care by a wide margin. Templates exist that have no relation to quality, or to efficiency. Physicians need to grind through appropriate templates that have been proven to lead to quality of care, and work to increase the efficiency of said templates.
Physicians have the sense that all of their appointments are urgent, and important. Such is not the case. Opportunities should be seized when a patient presents with a triviality, such as earwax impaction. Yes, to that patient this is an important problem. It needs to be addressed. However, the astute physician should smell the smoke and attempt to intervene with tobacco abuse.
Intervene one must, and do the template, so the interaction can be measured and quantified. Clear information on the status of the physician’s population of patients in comparison to the local region, province, and country can aid in appropriate allocation of healthcare resources and focus research.
“Will higher lever EHR use help a physician complete high quality patient records in a thorough, medically and legally sound, timely and efficient manner?” There is the quick thing to do, and the right thing to do. Research, overall, clearly suggests that high-level use of the EHR, including the use of templates, produces quality gains. Thoroughness appears adequate. In time, the “sound” medically, legally appropriate approach to record keeping may be that template: there may come a day when their use is mandated.
A strategy to develop a good cognitive map of the software and elevate EHR competence is necessary. This maneuver will, hopefully, gradually impact on overall in clinic efficiency. The quality of records, and patient care, should improve.
A physician champion will be sought to provide further EHR training. Records, patient care, and clinic flow will be examined after this intervention.
Novel uses of the EHR may be explored in clinic. There is a new application of the computer where patients can be given tablets with which to fill out questionnaires (Kavanagh & Kavanagh, 2013). These questionnaires can then be automatically uploaded to the patient’s chart. This has a potential for both improving care, and saving time, clerically and professionally. Patients may become more engaged, feel empowered, and help create their own solution, perhaps improving the patient-physician dynamic that is felt to be deleteriously affected by EHR use (Blakeman et al, 2011).
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CAPSTONE PROJECT DOCUMENTATION FORM
Action Research is an exciting, disciplined process of discovery designed to integrate theory into one’s daily practice in a way that improves educational practices and the individual conducting the research. Action Research is the Capstone Project in the Master’s of Education program for Concordia University online. It gives the educator, as a scholarly practitioner, the opportunity to examine relevant issues in his or her own classroom or school which may complicate, compromise, or complement the learning process—and to find meaningful, practical, research-based answers.
In Action Research, teachers are empowered to design a research-based plan, identify learning issues or problems, review relevant literature that examines identified problems, implement specific, research-based strategies, and discover convincing evidence that supports or contravenes their teaching strategies. The most exciting part of Action Research is the teacher can often observe student improvement during the project and can demonstrate, in a quantitative manner, the improvement of student learning. Sagor notes, “Seeing students grow is probably the greatest joy educators can experience” (2002, p. 5).
The steps to the Capstone Project are detailed below. Read through all of the steps before creating your implementation plan. Save this form as a draft until all Action Research steps have been completed and all responses are documented. You will submit this form at different stages of completion throughout EDU 698.
ACTION RESEARCH PROJECT
Name: Ron Ireland
Title of Project: MD Documentation Strategies
Date Completed: 2013, Nov. 8
IMPLEMENTATION TIME FRAME:
Number of weeks: 2
TIMELINE of ACTION RESEARCH PROJECT:
Start Date: 2013, Oct 21
End Date: 2013, Nov 1.
AREA OF FOCUS: What is your chosen area of focus? Why did you choose this area? How does it directly impact you?
Physician clinical documentation is the area of focus for this action research project. Canadian physicians see a large volume of patients, especially if located rurally. Keeping up with documentation, while maximizing access, can be a challenge. Patient flow and access could be improved by a more timely completion of patient records. The challenge of course is to retain high quality patient interaction, or even improve it, while also creating records of high quality.
Doctors are confronted with often- mandated new technology for health records, largely unable to efficiently document patient interactions in the way they have been traditionally taught. Improving documentation could lead to not only better patient care through provision of automated reminders and guidance, but also possibly an improvement in efficiency.
“Will higher level EHR use help a physician complete high quality patient records in a thorough, medically and legally sound, timely and efficient manner?”
DEMOGRAPHIC DATA: Where/What is the research site? Who is directly involved? What statistics will give a clear understanding of the context and culture of the research site? (Do not use name as an identifier.) Provide references for sources used.
The research will be conducted in Lincoln, ON, a Niagara region town of 23,000 on southern Lake Ontario. The demographics of this area is diverse: Niagara is the second most popular retirement area in Canada behind Vancouver; from here, a short commute is possible to Toronto, Canada’s biggest city; Lincoln has residential, commercial, agricultural, and light industrial areas.
Within Lincoln there are 2 groups of family physicians, and one solo GP. Lincoln lies next to Grimsby, a larger town with also 2 family physician groups, with a community hospital. Smithville (a town a little further, one group), Lincoln, and Grimsby physicians all have what is called a hospital-based practice. Physicians see patients in ER, their clinics, on house call, admit to this hospital, and follow their own patients. Patients come to clinic for preventive care, acute illness, emotional assistance, and occasionally for emergencies.
The researcher is the senior physician, part clinic owner of one of the Lincoln groups, this particular group comprised of seven physicians. The research site is this family practice clinic only, and the people involved will be primarily that senior physician, and his patients that identify themselves as needing assessment during the weeks of implementation. Secretarial staff will be involved in tablet setup for patient questionnaires. Nursing staff will be involved in the preliminary assessment of some interactions: well babies, prenatal visits, and annual physicals primarily.
TARGET GROUP: Who are the students you are trying to impact? (Do not use names – you must use another identifier.) How do you think this strategy or content focus will benefit the target group?
Patients that will be possibly influenced by changes in documentation strategy will be from the researcher’s practice primarily, a group of roughly 3000. Occasionally, a patient identified as being a member of a partner’s practice will be assessed. Consecutive patient physician interactions during the implementation time frame will be examined. The use of templates may lead to more complete investigation and documentation of patient concerns.
BASELINE DATA: What are the baseline data that support your choice for this area of focus? What patterns or trends do you see in the data? What is your proof that an issue exists in this focus area? (NOTE: You may not depend solely on Standardized Test Scores.)
Physicians are taught to report in a concise narrative format (Han & Lopp, 2013), often hand written. The use of electronic health records (EHR) in the clinic setting has brought legibility to the clinic. EHR for clinic use is still however far from ubiquitous; in 2011, 54% of all physicians in the U.S. were reported to be using such a system (Jamoom, Beatty & Bercovitz, 2011). Use is increasing quickly. In 2012, 69% of U.S. physicians were using EHR. Canadian statistics show an increase from 37% in 2009, to 56% in 2012 (Schoen, Osborn, Squires, Doty, Rasmussen, Pierson, & Applebaum, 2012). EHR is widely touted as the savior of quality, and a tool for efficiency. Such are the clear claims of EHR suppliers.
Many, if not all, EHR’s support the traditional style of narrative notes. However it is perhaps a safe statement to assume that fewer older physicians excel at typing or have computer expertise. Younger physicians were significantly higher users of EHR than physicians over the age of 50 (Jammu et al, 2011). Perhaps to partly address this issue, this researcher has found that EHR providers have supplied a list of templates that can be used to document encounters. Templates have a defined structure, in essence a series of fill in the blanks, or click and insert type options.
Templates have advantages apart from ease of data entry (Hann et al, 2013). Many templates are built based on current best practice guidelines. There are physician reminders built in. The use of a template can also aid analysis of medical information. A physician could do a study on his own practice, looking at goals for diabetes, for example: how much of the patient population has seen an optometrist or achieved blood goals? The information held in a template is “more findable” by the computer for analysis. This kind of documentation, however, can be fragmented, and stored in different areas of the chart (Han et al, 2013).
Physicians simply aren’t trained to read charts presented in such a fashion. In 2009, only 64% of U.S. medical schools allowed students access and use of the EHR (Han et al, 2013). EHR training programs tend to focus on documentation skills, not reading and processing skills. Despite adequate hardware and software, many physicians persist in documentation styles that existed with the antiquated, no longer used paper charting system.
Thus, we have here a senior physician more comfortable with paper charting, attempting to use the EHR to best advantage, to move beyond charting on computer in the same way he did on paper. It is hoped that new strategies will not only lead to complete records, but better, perhaps even more timely and complete patient care.
IMPLEMENTATION PLAN: What is your plan to implement the strategy or content knowledge? How did you collaborate with other staff involved with this issue?
Research, overall, clearly suggests that high-level use of the EHR, including the use of templates, produces quality gains.
A strategy to develop a good cognitive map of the software and elevate EHR competence is necessary. This maneuver will, hopefully, gradually impact on overall in clinic efficiency. The quality of records, and patient care, should improve.
Novel uses of the EHR will be explored in clinic. There exists an application of the computer where patients can be given tablets with which to fill out questionnaires (Kavanagh & Kavanagh, 2013). These questionnaires can then be automatically uploaded to the patient’s chart. This has a potential for both improving care, and saving time, clerically and professionally. Patients may become more engaged, feel empowered, and help create their own solution, perhaps improving the patient-physician dynamic that is felt to be deleteriously affected by EHR use (Blakeman et al, 2011).
The clinic manager has been instrumental in assisting the researcher: wiring the clinic for wireless tablet use, researching and acquiring hardware, assisting in support staff training for higher level EHR use (tablet support), collating anonymous surveys. Nurses and support staff will step out of comfort zones to assist with EHR template use prior to physician assessment. A physician champion in another clinic has been sought to provide further EHR training to the researcher. Templates embedded in the EHR software will be used to full advantage, with every patient interaction.
Records, patient care, and clinic flow will be examined after this intervention.
To restate and simplify:
1) The physician will learn to use the computer prior to implementation, and will use templates for charting.
2) Staff will help with hardware, and collating anonymous surveys.
PROCEDURES & MEASURES: What are the steps you will follow? How will you measure student progress?
Patients call in to the office for appointments, usually self-declaring the need to be assessed. Consecutive physician patient interactions will be studied during the implementation period. The researcher will examine his day sheet (list of patients) before clinic begins, and decide what kind of template will be used. An attempt will be made to pre-insert appropriate templates in the EHR. Routine problem oriented assessments will start with a “S.O.A.P.” template (subjective, objective, assessment, plan). Patients identified by the researcher during the appointment as requiring a specific template for a specific problem, such as diabetes, will have that template inserted in the chart at the time of the appointment. Some patients will be offered a pre assessment questionnaire, notably those parents bringing children for routine periodic care, patients with mood disorders, and patients with several other well defined typical problems for which these types of assessments exist. These pre assessment questionnaires are completed by the patient himself or herself, and are automatically uploaded to the EHR.
The physician researcher will assess the patient as usual, and observe during this process if the template forces a change in interaction, patient demeanor, affects efficiency, or contributes to completeness. Daily notes will be taken in a diary directly after the patient appointment, so impressions will not be lost.
Patients will be offered the opportunity to fill out an anonymous satisfaction survey on their way out. They will not be identified on the form, and will have an opportunity to give free feedback on the interaction. These surveys will be dropped in a sealed box, and collected by the office manager to collate. The office manager will give the physician a summary report on these surveys, including all raw data on unsolicited freeform (handwritten, non check list type) feedback.
The researcher, at the end of the day, will compare interactions on that day with similar encounters of several months ago, before template use. Impressions will be journalized.
At the end of the implementation period, one partner will give her impression of several types of physician interaction compared to those experienced pre intervention (for example, prenatal visits, well child visits, routine problem based visits, psychotherapy) on a Likert scale: A lot worse, worse, neutral, a bit better, a lot better.
During the implementation period, the researcher will be cognizant of the amount of time taken to complete charts with these new methods. There is a facility on the computer to measure appointment length, but it is fairly clumsy. An attempt will be made to use this.
DATA COLLECTION: What data will be collected? How often? What tools will be used? Copies of tools will go in appendixes.
Diary: Daily entries will be made of the researcher’s impressions of patient appointments. Appointments that go fairly routinely with no apparent change will evoke no data entry. However, any unexpected change in patient demeanor, efficiency, or completeness will be noted.
Satisfaction Survey: This will be offered to each patient during the implementation period.
Journal (Comparison with previous interactions): At the end of each workday, encounters will be compared to similar encounters from several months prior to the implementation. Impressions will be journalized.
Physician partner Liker scale: Completed at the end of the project, one partner will give an opinion on overall charting quality compared to before implementation. (Much worse, worse, neutral, better, a lot better).
IMPLEMENTATION: (Describe the actual implementation of your plan.)
Week 1: 2013, Oct 21-25.
Prior to seeing any patients during the implementation period, the researcher reviewed his day sheets and determined if a patient visit would at all fit any standard templates, whether they are patient tablet (patient self questionnaire) or physician directed templates. These templates were identified on the patient chart for use by support staff. A staff member would find the template in the software and load it on the patient tablet, if applicable.
Oct 21, start day of implementation, was marred by the lack of patient tablets, which did not arrive on time. The researcher began the project in spite of this, utilizing Electronic Health Record (EHR) templates extant. Every patient interaction was documented with a template, often “SOAP”, (Subjective, Objective, Assessment, Plan). At the end of that day, and each subsequent clinic day, impressions from the patient visits were documented on the daily journal spreadsheet. The researcher then compared implementation charting vs. charting from several months ago, and made a decision whether the note was worse, to improved, and documented this impression on a Likert scale.
Patient questionnaires were distributed this day (Oct 21), for the first time. Intentions were that every patient seen by the researcher would be offered at least a chance to fill out this anonymous survey (see appendices). Parents bringing small children would get the survey, as would caregivers of disabled patients unable to complete it.
Some staff members remembered to distribute the questionnaires better than others. The first day was more difficult in this regard, but many questionnaires were collected.
Oct 22 saw the arrival of patient tablets. These were set up and initiated by the office manager. During this process it was decided to change the documentation of desired template from the chart to the appointment schedule (day sheet) for easier access. Messages were thus transcribed. Tablets were first ready to be distributed to appropriate patients on the afternoon of this day (Oct 22); however, no patients fit criteria.
Oct 23 had a surprisingly few template problems, with only one failing to download. Tablets continued in use Oct 24 and 25.
Patients on the whole had no problem filling out the tablet questionnaires, with one elderly patient clearly delighted to be touching a tablet for the first time. No patients were overwhelmed, or thought the tablet was inappropriate in any way. In contrast, patients volunteered that tablet use was progressive.
In retrospect, secretaries reported that less patients filled out post visit physician assessment/ satisfaction questionnaires post tablet use. (More patients filled out the post visit survey if they did not have an electronic tablet pre visit questionnaire).
During every visit, Oct 21-25, patient visits were documented using a template of some type. Often the visit started with “SOAP”, but then proceeded to include or transfer to other templates, such as rating scales for mood disorders, or diabetes or heart failure templates.
After this week, it was felt by the researcher, looking back, that some appointments would have gone smoother, the interpersonal connection could have been better, if the computer was accessed at a later time, for example patients with mood disorders, or patients that were distraught.
Week 2: 2013, Oct 28-Nov 1.
Oct 29 through Nov. 1 proceeded in the same manner as above, with patient visits documented using templates. On Oct 28 only one patient was seen in clinic emergently as it was a designated OR surgical assist day.
One change in approach was initiated. If the researcher felt that the patient was distraught, then no movement towards the computer was initiated until the situation was settled. On some occasions, nothing was documented until the end of the day.
Reminders discovered at the end of the day, while doing templates, were either called to the patient, or marked for implementation on the next visit (for example, a vaccine).
Post visit doctor/ visit evaluation questionnaires were stopped on Oct 29, as it was becoming stressful for office staff to distribute and collect this data.
One elderly patient required tablet assistance on Oct 30 from a secretary however seemed intrigued by the gadget.
Oct 31 saw one elderly couple, their dysfunctional relationship strained by alcohol abuse and depression, fighting over responses to a questionnaire on the tablet. The researcher had to intervene. This couple, however, did not report that they thought the tablet was inappropriate. They did report that they had not seen one before and were unsure of its use.
A physician partner was given an assessment form upon which to document her impressions of chart notes during implementation compared to past notes on Nov 1.
DOCUMENTATION OF ADJUSTMENTS: How did the plan change during the course of the Action Research timeline? What prompted the change? What were the effects of the changes?
Slight adjustments occurred. Lack of availability of patient tablets during the first day, and the necessity of quickly setting up the second day was an issue. Day one and two of implementation were used utilizing templates already in the system to best advantage. After tablets were available, patient generated questionnaires were added to some interactions. (Not every interaction required a patient tablet, nor was there one available for every circumstance and situation.)
Early on in implementation, conscious effort was made to begin each interaction with searching for a template. By the end of the first week, although this approach held certain advantages, it also revealed real drawbacks: some interactions, by reason of the nature of the problem, or the nature of the patient, were somewhat disrupted by immediate computer template use.
During the second week, there was a more judicious use of templates: on many occasions, templates were used early in the appointment, on others; templates were imposed on the chart later. Early use made available automated reminders that could help medical decision-making. Later template use allowed for an immediate face-to-face interaction without the mediation of electronics. Documentation of these interactions later on said template occasionally revealed missing considerations or maneuvers that would have to be completed at a later date.
Patient post visit (doctor rating) questionnaires were occasionally forgotten for brief periods during the implementation period. This occurred due to support staff oversight, and was independent of the nature of the clinical problem or the patient. For this reason, these oversights are considered random events, probably not of significance when it came to analysis.
The computer tool to document in and out time proved too unwieldy to use. Time was recorded manually.
ANALYSIS & REPORTING
REPORTING RESULTS: What are your results and how will you share them? How does the baseline data compare to the ending data? What is the story told by your data?
The daily diary, which included a Likert scale and a comparison to old records, charted 66 entries, of which included a daily item for multiple minor problems. Day one had 16 minor issues, charted under one entry, day two had 14, and subsequent days listed only “multiple”, with no specific number entered, likely a similar amount.
Problems represented in the two-week chart (9 days) covered the spectrum of family medicine, from consults for hypnosis, to blood pressure checks, to diabetes, to a violent patient. Entries were not done if an interaction went very much as before: these included prenatal and pediatric exams, for which templates have been used for ages. In other words, if no new charting or documentation technique was used, if the visit was fairly identical to visits prior to the implementation period, then nothing was entered.
Time involved to see the patient and chart during implementation, which may be distortional due to implementation dip (Sagor, 2011), was felt to be clearly higher on the whole compared to old notes. There were some exceptions to this: fibromyalgia contacts were overall similar in length (4) and in one circumstance shorter (1), but all associated with tablet use provided a measurement never before done; chronic pain contacts were perhaps shorter (2) or no longer (2); back pain assessments, initially longer became quicker during implementation, associated with learning the template and self education (6); mood disorder management actually quicker and more appropriate usually (5), longer in one circumstance (1), similar in another (1); sore throat assessments were quicker (2); headache perhaps quicker (1).
In regards quality, of the 66 entries, four were considered worse, all minor problems. Here, templates were either not used, or used badly and then edited out because of volume and rushing. There were 14 entries considered a lot better, and 18 entries neutral. The rest of the encounters during the implementation period (30) were considered of better quality compared to prior, old notes. On the whole, therefore, the use of templates during implementation clearly improved the quality of data entry and/or patient interaction.
Those 14 much improved documented encounters ranged from 10 to 70 minutes in length. Patient generated (tablet) questionnaires were associated with 7 of these entries. The median length of time was 20 minutes (8 entries). The average length of time was 24.8 minutes. These encounters were considered improved because of the templates allowing a more complete diagnosis and plan (the majority, 5), a fuller more accomplished exam (2), they revealed a hidden symptom of great importance (suicidality, 2), they helped teach the researcher (Canadian Back Institute classification, 3), they helped focus on a more pertinent syndrome by ruling one out (1), or allowed measurement of a previously fairly vague entity (palliative burden, 1).
18 entries were felt to be neutral. The number here is distortional, as entries for multiple minor problems also fell into this category on more than one occasion. This category represents many more than 18 patients. Another distortion is the perception by the researcher of the SOAP template. Initially there was surprise that the template encouraged examination, leading to a higher-level Likert scale rating. After the surprise settled, there were a couple of days of “neutral” gaging. Later in implementation, the use of SOAP tended to produce an impression of higher quality, perhaps using the template better, or recognizing the actual improvement. The range in appointment time for the neutral entries was from 5 to 60 minutes. Patient generated (tablet) questionnaires were associated with 4 of these entries, templates that were considered to be largely superfluous and non-information generating (the hypertension and knee pain templates). It is difficult to discern here the median length of time as entries included multiple minor problems, but it was likely 10 minutes or less. The average length of time is similarly difficult to calculate, but the researcher’s impression is that it is likely approximately 10-15 minutes. Three of these entries were likely somewhat improved on later reflection, the SOAP template allowing more organization. Other reasons for neutral status were inadequate time for template use (1), more formal only (1), multiple SOAP entries which were at some point routine to the researcher (many), standard templates previously used pre implementation (2), triviality (1), and the reluctance of the researcher to share a diagnosis with an unstable bipolar patient (1).
The bulk of the results that were found to be better (34) were improved primarily because of the use of the SOAP template, for which there were many entries, including that nebulous multiple minor problems entry. Again, the number of 34 is distortional (low). The range in appointment times for this category was from 5 to 50 minutes. The median length of time was 10 minutes, with multiple minor problems making up most of this (likely ~ 90 visits). An average length of appointment for this better category is judged to have been approximately 12 or 13 minutes. SOAP was found to lead to more logical separation of problems, enhanced organization, and an encouragement of the researcher to examine the patient (do physical exam). Other templates allowed a fuller history (11 entries), allowed measurement of a difficult symptom complex (fibromyalgia, 4), allowed a statistical score (McIsaac score, 3), sped inquiry (3), or helped confirm stability (PHQ-9, 2).
The daily diary spreadsheet highlighted those visits that were complemented by a questionnaire filled out independently by the patient before the encounter on a tablet. No minor problem had a tablet associated. Every encounter with a patient tablet questionnaire was documented (26). Seven of these interactions were considered by the researcher to be of a much higher quality. Four were considered neutral, and the rest were considered to be of higher quality.
The UK patient satisfaction surveys, distributed as the literature review appeared to indicate that some patients found the use of the computer and templates to be disruptive to the medical interview, failed to demonstrate any such thing. Questionnaires were highly supportive of the researcher; there was no negative volunteered feedback about the implementation process.
A physician partner was asked to look at current (implementation) chart notes and compare them to notes done prior to this two-week period. The physician only gave concrete feedback on four patient interactions. One was felt to be worse, a patient who was seen for hypertension. Interestingly, this template was felt by the researcher to be non-helpful. Despite this, it appears that the researcher relied on this template to provide information, and only inferred, but did not specify the assessment and plan. Three other assessments, one back pain, one fibromyalgia, one CHF patient (congestive heart failure), were all deemed to be of better quality (2) or much better quality (1, the fibromyalgia patient). Generally, the physician partner felt that the “SOAP” format led to clearer, cleaner, more intelligible notes compared with prior efforts.
To summarize, patients did not seem to be averse to the physician use of templates, or their own use of tablets for pre visit screening. This researcher found that the overall quality of the documented interactions was improved during implementation, in some cases drastically. SOAP allowed for a clearer presentation of data and surprisingly seemed to lead to increased physical exam. Other templates allowed measurement and description of difficult symptom complexes (palliative burden, fibromyalgia), helped to flesh out history, speed inquiry, and confirm impressions. Statistical analysis and treatment recommendation was included in the sore throat template (McIsaac score), and one template actually led to the researcher learning a new back pain classification.
Most to the point, however, the templates explored in this implementation period could have saved lives. Two patients followed quite closely, who in the past denied suicidality to the researcher, were able to confess this most difficult to divulge symptom on a patient tablet. This led to concrete specific changes in management. If this were the only positive outcome from this study, it would be well worth it. The electronic medical record clearly proves itself here to be a medical instrument, and one of great value.
Initially began to find a way to become more efficient with charting, this action research project has revealed and confirmed a basic fact in medicine. There is no rushing quality. Very basic problems usually took longer, but produced better notes. The occasional very complex interaction was perhaps shorter, with again better notes, and higher quality. Outcomes were better. Quality is better. Quality will stay better.
Again, the compass wins out over the stopwatch (Covey, 1989).
Please see appended raw data:
1) Patient Questionnaire Summary
2) Diary/Journal notes spreadsheet
3) Clinical problem vs. Time/ Quality table
4) Physician Partner Likert Scale
IMPLICATIONS FOR FUTURE: How will the results impact your teaching in the future? How did the project inform your decision-making as a professional?
This Action Research (AR) endeavor has been career changing for this researcher. Apart from learning a respect for qualitative research during this process, an actual change in practice evolved over a two-week implementation period. A thorough literature review led to a new perspective on a basic day to day component of medical care, how to “write it down”. In the process of implementation, it was rediscovered that the chart is not only a documentation of an interaction, but a tool for patient care itself, in essence a medical instrument. It is difficult to ignore data collected yourself.
Beyond changes in documentation and approach to patients (see below, conclusions), AR has revealed itself to be a potent strategy itself, an approach to medicine. A physician interacts with his practice, his patient cohort, in a way much like a teacher with a class of students. If one approaches medicine in such a way, and chooses to analyze not only clinical outcome but consider all possible aspects of care, one should prove to be more a more effective physician. AR is a way to become a more scientific, analytical practitioner.
In my role as a clinical teacher, I will present qualitative research as a potentially valid avenue of inquiry, a perspective traditionally not held in medicine. AR will be presented as a way of analyzing one’s practice, and a potential method to improve outcomes. I will need to teach my students to do Action Research.
CONCLUSIONS: Did this study improve student performance? Explain. Did this study improve your skills as a teacher? Explain.
Do patients perform? Certainly physicians do. This study improved the researcher’s performance in regards not only quality documentation of patient interactions, but in providing quality health care. This study improved my teaching skills by illustrating the importance of Action Research in medical practice. New graduates need to approach medicine from an additional new perspective: that of the social scientist. I will need to put this into practice. This is a whole new aspect of clinical teaching.
Did the study affect patient performance? Patient deportment was occasionally affected by the use of templates. This was recognized in week one, and led to an adjustment in week two. Some kinds of interactions simply cry for direct knee-to-knee, face-to-face communication not mediated by a computer, or any other note taking device or apparatus. As soon as it became apparent that such an interaction was occurring, the researcher learned to turn away from the computer, and address the template at the end of the day. Certainly, as a result of template use, the interventions at times changed, and thus did the patient’s course of action.
The researcher found a new commitment to using “SOAP” regularly, a simple template that forced an organization on to a charted patient visit. “SOAP” was actually felt to increase the amount of physical exam done by this researcher during a visit, and forced a clear documentation and commitment to a diagnosis. Many older chart notes inferred diagnoses (that would be obvious to another health care professional).
Many specific templates were actually found useful in making the interaction more complete, suggesting investigations, aspects of physical examination, or even consideration of uncommon diagnoses. The researcher actually learned a categorization of back pain that he was hitherto unfamiliar with. Such experiences imply that templates written based on best practices can actually not only change physician behavior, but also teach physicians.
Blakeman, T., Chew-Graham, C., Reeves, D., Rogers, A., & Bower, P. (2011). The Quality and
Outcomes Framework and self-management dialogue in primary care consultations: a
Qualitative study. Br J Gen Pract. 61(591), e666-73. doi: 10.3399/bjgp11X601389.
Han, H., & Lopp, L. (2013). Writing and reading in the electronic health record: an entirely new
world. Med Educ Online. (18), 1-7. doi: 10.3402/meo.v18i0.18634.
Covey, S.R. (1989). The seven habits of highly effective people: restoring the character ethic.
New York: Free Press
Jamoom, E., Beatty, P., & Bercovitz, A. (2011). Physician adoption of electronic health record
systems: United States. NCHS data brief, no 98. Hyattsville, MD: National Center for
Health Statistics. 2012.
Kavanagh, D., & Kavanagh, J. (2013). A new way to practise medicine: Innovative technology
to integrate clinical guidelines into practice. Retrieved from
Ministry of Health and Long Term Care (MOHLTC) (2012). 2103/14 Quality Improvement Plan
Guidance Document for Ontario Hospitals. [pdf] Retrieved from http://www.health.gov.on.ca/en/pro/programs/ecfa/legislation/qualityimprove/QIPGuidanceDocument.pdf
Sagor, R. (2011). The Action Research Guidebook: A four-stage process for Educators and
Schoolteachers, 2nd ed. Thousand Oaks, Cal: Corwin Press
Schoen, C., Osborn, R., Squires, D., Doty, M., Rasmussen, P., Pierson, R., & Applebaum, S.
(2012). A survey of primary care doctors in ten countries shows progress in use of health
information technology, less in other areas. Health Aff (Millwood). 31 (12), 2805-
Action research has a potential for revolutionizing medicine. These research techniques can be applied to many aspects of a physician’s practice, and can improve patient care. Unfortunately, most physicians come from the natural sciences, and have been trained a prejudice against the qualitative study.
Quality Improvement Projects will soon become mandatory for all physicians in Ontario (MOHLTC, 2012). The Ministry of Health (MOH) is mandating the evolution of Action Research like projects. Many physicians will find themselves lost.
Social science programs, much like this one, may be of interest to physicians wishing to affect quality improvements in patient care, and meet MOH requirements.
Patient Questionnaire Summary
UK General Medical Council patient satisfaction/ physician assessment questionnaires were given to patients seen between the dates of Monday October 21st and Tuesday October 29th, 2013 in clinic.
Beginning on the afternoon of Tues, Oct 22, staff began presenting some patients with tablets for pre assessment questionnaires. Support staff noticed that patients completing a pre visit questionnaire were less likely to complete the post visit satisfaction questionnaire. This was noticed in retrospect by the staff. There was no hard data collected to describe this phenomenon.
A total of 161 patients were seen during this time; a total of 82 (51%) questionnaires were completed. Seven patients left the second page totally blank. Four patients left the gender section blank. (11 surveys therefore had no gender identified).
Gender <15 15-20 21-40 41-60 60 +
Male (30) 2 4 8 16
Female (41) 2 1 6 16 16
On the survey, patients identified their presenting concern:
Treatment, including Rx renewals 29
One off problem 8
Routine check 8
Advice and or ongoing problem 25
Of the total, 63 rated that their reason for attending the physician was “important” to “very important” to their health and wellbeing, with only 19 patients rating this “not very important” to “neutral” on a five point Likert scale.
In regards confidentiality and honesty (question 5), 2 males felt that there may be a problem in this area. Despite this, ALL males did feel they were confident in the physician’s ability, and would be happy to see the physician again. 4 females had concerns with confidentiality and honesty, but again, ALL females completing page 2 were confident in the physician’s ability, and would be happy to see the physician again.
Likert scale questions relating to physician engagement, abilities to assess, explain, involve the patient in decision-making and arrange treatment revealed that 80 patients felt the physician was “good”, or “very good”. One patient who indicated “poor” for all areas also felt the physician was “very trustworthy” and would always come back. One patient listed as “satisfactory” for involvement in decisions about treatment, but every other category “good” to “very good.”
Patient Feedback (an area on the survey for handwritten feedback)
There were no negative remarks or feedback in regards the tablet use, the use of templates during the encounter, the use of the computer during the visit, or the tone of the interview. All written statements were highly supportive of the researcher.
A link to see the original, blank questionnaire that was distributed:
This questionnaire has been thoroughly vetted in the U.K., a medical system much like the one the researcher works in, with a fairly similar type of patient base. There is apparently no similar standard questionnaire that has been developed for Canada, although family MD’s in health organizations are expected to do patient satisfaction surveys. There are standard questionnaires available for the U.S. market, but the medical system is too dissimilar; a large part of those surveys are related to affordability, value for the money, in essence economic concerns, all of which are not an issue for a Canadian patient.
Source for questionnaire:
GMC Questionnaires and Resources. (2013). General Medical Council: Regulating doctors,
Ensuring good medical practice. Retrieved from
Action Research Diary/ Journal notes, a spreadsheet
Please click on the below figure to expand it.
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Clinical Problem vs. Time/ Quality
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Physician Partner Quality Scale
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