Tuesday, November 15, 2011

Can we do better than SOAP?

So I've recently been looking at some of the most important standards we have, that few people appreciate. Some standards that I've recently been admiring the beauty of :
  1. The 110-volt AC plug in America - Thank goodness for this! Imagine if you had to worry about which coffee maker you could or couldn't buy because it didn't have a plug that fit your house! (Or even better, think about how challenging it is to travel with that same coffee maker to a different country!)
  2. Traffic lights - Thankfully, they all behave the same in our country. Imagine if driving from Maine to Florida meant having to learn different traffic signal patterns?
  3. Traffic patterns - We all drive on the right side of the road in the U.S. - Imagine having to change as you drove state-to-state? (I wonder how they handle this in the Chunnel between France and England?)
  4. Train tracks - Snopes.com has this interesting debunking about railroad gauge, that includes a mention of how during the American Civil War, the northern railroads had one gauge while southern railroads had multiple gauges -  this was argued by historian James McPherson to be one of the logistical factors that contributed to the Union army winning over the Confederate army. (And interestingly, after the North won the war, many of the southern railroads were rebuilt by the North, giving us the American standard of 4 feet, 8.5 inches.
  5. The Apple iPhone/iPad/iPod charger - Although Apple toyed with some of the charging pins since the iPhone 3G, the plug has essentially been the same since the original iPod in 2001. Now it seems that since the iPhone 3G, you can use the same plug to charge your iPhone 3G, iPhone 4, iPhone 4S, iPad, iPad2, iPod Touch, and various other apple devices. I suspect this is why the plugs are becoming so ubiquitous that most of my friends now seem to have one in the kitchen just to let visitors charge their Apple devices.
  6. American Standard Code for Information Interchange (ASCII) - This is arguably much larger than just an American standard - Although Unicode has expanded the ability for designing documents, ASCII is probably the most widely-used standard in computing.  Can you imagine if your processor didn't know you pressed the "A" key on your keyboard? What if that "A" didn't show up on the screen? What if you sent an email and the "A" didn't arrive?
  7. Internet Protocol (yes, both versions 4 and 6) - The Internet would not be possible without a standard Internet Protocol
So I think we can all agree that these standards are good for us - And thankfully for healthcare, the ANSI (American National Standards Institute) created a new HITSP chapter in 2005 after the ONC recommended someone start working on healthcare IT standards. (A shout out and thanks to John Halamka, MD for taking on this labor of love!) :)

Anyway, I think the take-home message about healthcare IT standards is that we're still really early in the process. (As of this writing, the HITSP has only been around for about 6 years!)

So because a lot of my work as an informaticist deals with the struggles to achieve standards, I think a lot about the final objective of informatics : Getting the right information to the right person in the right place at the right time in the right way. (It's easy to get 2 or 3 of those right, but getting all 5 right is much more difficult.)

Anyway, so it's nor surprising that I eagerly await the day when the Regional Extension Centers (RECs) and Implementation and Optimization Organizations (IOOs) finally make the HIEs that smoothly link our electronic medical records - ... But what then?


In my quest to get the right information to the right person in the right place at the right time in the right way, it dawns upon me that the best technical solutions may still fall short of expectations because of this : There aren't really any good standards for the content of electronic documentation.

In fact, I started to ponder - What standards are there, at all, for clinical documentation?

Most practicing physicians can pretty quickly think of one real standard - The SOAP note. It stands for "Subjective, Objective, Assessment, and Plan", and is a rough outline for how you write a note in a logical way :
S - Subjective - What you heard from the patient (history, opinions, and answers)
O - Objective - What you saw about the patient (measurable things or physical findings)
A - Assessment - What you believe is currently going on with your patient
P - Plan - What you and your patient are going to do about it
The SOAP note is also a cognitive framework for how we think and communicate about patients - When you sign out to another physician, the SOAP note influences our thinking and what we say or write about our patients. By forcing a physician to confront the evidence (S, O) before rendering an opinion (A) and plan (P), it has had a remarkable impact in improving the quality of care and communication about that care.

Interestingly, the history of the SOAP note goes back to this seminal paper written by Dr. Lawrence Weed, published in the March 14th, 1968 edition of the New England Journal of Medicine. (Click on the link above to read the actual article.) 


One of the fascinating parts about this article is in its opening paragraphs - The purpose of this paper, in 1968, was "...to develop a more organized approach to the medical record, a more rational acceptance and use of paramedical personnel and a more positive attitude about the computer in medicine." Snark Alert : Amazing how far we've come in the last 43 years!

But getting back to serious discussion, the paper highlights many of the struggles we have had with implementing EMRs in the last 40 years - And still continue to struggle with today. When you read the article and see how notes were structured BEFORE the SOAP structure, you can see why some people argue he should win a Nobel Prize for Medicine

It's also good to know Dr. Weed is still developing his argument, as published in this 1997 British Medical Journal article. (THANK YOU DR. WEED!)

But then I thought : We have the SOAP note - But do we have anything else to help guide us?

Since most medical schools teach little about clinical documentation (you're usually too busy learning about diseases), many doctors finally learn about note writing from pocket books like the Washington Manual Intern Survival Guide. (Similarly-themed but shorter "Intern Survival Guides" can be found here and here, just to get an idea of what I'm talking about.)

So if most of our education for physicians about writing notes falls down to these pocket guides, and the notes are often specialty-dependent but built on the SOAP framework - It's no wonder we all struggle with electronic documentation.


Anyone who has worked on electronic documentation will tell you : It's hard to build, and hard to maintain.

The first challenge is getting a note built - What exactly will you use the note for? What will you name it? What do you want to include in the note?

Looking for answers to these questions often depends on :
  1. The planned clinical scenario
  2. The physician's experience
  3. The physician's pocket guide they learned from in Internship
  4. Regulatory and compliance issues (the stuff that insurers and other regulators want to read about)
The funny thing is, every hospital is working on this same problem separately - Often coming out with similar but slightly different results. It's a great example of "everyone rebuilding the wheel".

Why can't all Medicine History and Physicals look the same? In my experience, most of them approximate the same SOAP format, but I've even heard the argument, "I'd like to see the Plan at the TOP of the note when I read it." This speaks to a challenge of documentation in general - 
  1. Documentation is closely tied with our cognitive processes.
  2. Our cognitive processes, while similar, are not entirely standardized.
  3. Regulations, insurer demands, and clinical practices change frequently, making it important to maintain notes after they're built.
So in the end, clinical documentation is more expensive to build and maintain than most people imagine - And every hospital is having the same struggles together.

And because the notes may vary in their end result - An electronic note sent from a doc in one hospital one day may not have the best reception by the physician at another hospital.

In other words : I'm thrilled we're working to link our EMRs - But will the notes we send be equally effective at another hospital?


So we have a new, small, informal group of volunteer healthcare informaticists here along the Interstate 91 Corridor that stretches between New Hampshire/Vermont, all the way down through Massachusetts to New Haven, CT. We meet informally every 3-4 months for dinner to discuss healthcare informatics, and I'm glad to report we recently obtained a donated website, which we hope to develop. 

I'm hoping at our next dinner to propose a few crazy ideas to our group : 
  1. What if all of our documentation looked the same? (for the same clinical scenario...)
  2. Could all of our clinical documentation look the same? (for the same clinical scenario...)
  3. Could we develop a standard for content of electronic documentation?
  4. Could we help further develop the SOAP note, to provide a logical and cognitive standard that helps improve care and reduce costs for all of us?
  5. Could this framework be used as a teaching tool about clinical documentation in medical schools and residency programs?
Will let you know how things turn out after our next dinner. Look out for the I91 Standards. :) (Ooh, another cliffhanger, I know!)

As always, I love to answer questions. Feel free to respond with thoughts, questions, ideas, or other discussions. Remember : Education is a priority! :)


SpinalSnap said...

Why not look at the UK primary care market? The doctors in the UK have, pretty much, a uniform approach to the standard medical full note. So we're ahead of you to start with.

Once you look at moving towards electronic systems, the important entries are all coded - mainly using Read codes but in due course, SnoMed. The system suppliers have now implement what is known as GP2GP - direct electronic transfer of notes from one GP (family physician) to the next. More details at http://www.connectingforhealth.nhs.uk/systemsandservices/gpsupport/gp2gp

Transfer to secondary care providers is of course a different issue.

Iain Kewley
CCIO, Isle of Man

Dirk Stanley, MD, MPH said...

Yes, you're ahead of us - About 6 hours! :) Thanks for the tip, I'm going to check it out!