Daniel M. Stein

Quantifying clinical narrative redundancy in an electronic health record

OBJECTIVE Although electronic notes have advantages compared to handwritten notes, they take longer to write and promote information redundancy in electronic health records (EHRs). We sought to quantify redundancy in clinical documentation by studying collections of physician notes in an EHR. DESIGN AND METHODS We implemented a retrospective design to gather all electronic admission, progress, resident signout and discharge summary notes written during 100 randomly selected patient admissions within a 6 month period. We modified and applied a Levenshtein edit-distance algorithm to align and compare the documents written for each of the 100 admissions. We then identified and measured the amount of text duplicated from previous notes. Finally, we manually reviewed the content that was conserved between note types in a subsample of notes. MEASUREMENTS We measured the amount of new information in a document, which was calculated as the number of words that did not match with previous documents divided by the length, in words, of the document. Results are reported as the percentage of information in a document that had been duplicated from previously written documents. RESULTS Signout and progress notes proved to be particularly redundant, with an average of 78% and 54% information duplicated from previous documents respectively. There was also significant information duplication between document types (eg, from an admission note to a progress note). CONCLUSION The study established the feasibility of exploring redundancy in the narrative record with a known sequence alignment algorithm used frequently in the field of bioinformatics. The findings provide a foundation for studying the usefulness and risks of redundancy in the EHR.

Methodological Review: Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: A systematic review

PURPOSE The aims of this systematic review were: (1) to analyze the content overlap between nurse and physician hospital-based handoff documentation for the purpose of developing a list of interdisciplinary handoff information for use in the future development of shared and tailored computer-based handoff tools, and (2) to evaluate the utility of the Continuity of Care Document (CCD) standard as a framework for organizing hospital-based handoff information for use in electronic health records (EHRs). METHODS We searched PubMed for studies published through July 2010 containing the indexed terms: handoff(s), hand-off, handover(s), shift-report, shift report, signout, and sign-out. Original, hospital-based studies of acute care nursing or physician handoff were included. Handoff information content was organized into lists of nursing, physician, and interdisciplinary handoff information elements. These information element lists were organized using CCD sections, with additional sections being added as needed. RESULTS Analysis of 36 studies resulted in a total of 95 handoff information elements. Forty-six percent (44/95) of the information overlapped between the nurse and physician handoff lists. Thirty-six percent (34/95) were specific to the nursing list and 18% (17/95) were specific to the physician list. The CCD standard was useful for categorizing 80% of the terms in the lists and 12 category names were developed for the remaining 20%. CONCLUSION Standardized interdisciplinary, nursing-specific, and physician-specific handoff information elements that are organized around the CCD standard and incorporated into EHRs in a structured narrative format may increase the consistency of data shared across all handoffs, facilitate the establishment of common ground, and increase interdisciplinary communication.

Perspective: A framework for career paths in health systems improvement.

The difference between the U.S. health care system’s potential and the outcomes it delivers is vast and well documented. Fortunately, many medical trainees recognize this challenge and aspire to careers that will enable them to help close this gap by improving the systems of care around them. However, the career paths in health systems improvement are not well defined, and interested trainees are frequently left without clear direction. The circuitous and often serendipitous routes that many current leaders in health systems improvement—including medical researchers, health system managers, and policy experts—have navigated to reach their positions of influence do not provide consistent road maps for the trainees who wish to follow in their footsteps. The authors of this Perspective propose a framework to guide career development in health systems improvement. The framework is designed to help medical trainees and their mentors critically analyze various career options in three core focus areas (research, policy, management) and the intersections where those areas overlap (policy advising, implementation science, policy translation).The authors provide examples of the types of work done in each focus area and each intersection to help trainees make explicit decisions concerning skill development and to select opportunities that best fit their interests and strengths. In all, the authors intend the framework to support the development of a generation of physician leaders equipped to drive the improvement that the U.S. heath care system requires.

Commentary: time to sign off on signout.

The physician signout note is a widely used clinical document that supports patient safety and care continuity during patient handoff in the hospital. Despite its centrality to patient care, the signout note is not considered an official document, and it is, therefore, not generally standardized or taught to medical trainees, nor is it usually integrated into electronic health records (EHRs). This commentary outlines several of the potential advantages to establishing the physician signout note as an official part of the medical record, such as the facilitation of information flow between signout notes and other parts of the patient chart and the possibility of integrating decision support tools into this important aspect of the clinical workflow. The authors address frequently encountered concerns regarding the establishment of the signout note as an official part of the medical record. They conclude by making recommendations for integrating signout notes into EHRs and using modern, social Web technologies in such an implementation.