Wednesday, January 27, 2016

What is your EMR documentation index costing you?

It's all about the details. One of the things that I really love about front-line clinical Informatics is the remarkable insights you get into clinical operations - and how the tiniest, seemingly trivial design elements can strongly influence the cost and quality of patient care, as well as the cost of maintaining your EMR. 

When I first started, I didn't fully understand this relationship, and the focus of my attention was less on the names of notes and order sets, and more on their content. Fortunately, a respected Informatics colleague gave me this advice, early on :  "If you haven't struggled with designing a naming convention or a documentation index, you haven't done your job.

It took me a while to understand exactly what this meant, but through years of experience, it's become much more clear to me. So for educational purposes, I thought I would share the story of how I was recently reminded of this lesson, when I saw the following posting on a popular Informatics listserver (paraphrased here for brevity):

'I would appreciate your input on the approach you have taken to your folder or ‘hierarchy’ structure for documentation mapping.
We have robust use of our EMR in both the inpatient and outpatient setting. I have seen both ends of the spectrum when it comes to hierarchies:  Minimal number of note types to a very high level of specificity. We fall in the latter category and are always looking for ways to streamline and strike the right balance. Can you share the approach your organization has taken in this space? 
This may, in part, depend on how robust the search tools are within each EMR but I have some basic questions:

  • Do you have Outpatient notes separated from Inpatient Notes?
  • Do you separate notes by medical specialties?
  • Do you distinguish between a Resident and a Staff note? What about a Medical Student Note? (Do you take an alternate approach to distinguish between these such as the ‘signature line’ in the note proper or the template used for the note?)'
My response reminded me about how much the years of experience had taught me about designing naming conventions and documentation indexes. My paraphrased response is below : 


This is a great question! You have a great opportunity in front of you - This is the essence of what we do - Make it intuitive for people to understand and find their notes in the vast sea of information that is an EMR!

I’ve never been given the same challenge (although it would be a good one!), but I think I would start with a few guiding design principles

1. The name of the note should follow a standard naming convention.
2. The index of the note should be intuitive enough for both users and managers to be able to quickly find the information they need.

With those principles in mind, I might then use the Bell Labs North American geographic telephone number model (e.g. (xxx) xxx-xxxx (area code - prefix - identifier)) for paradigm inspiration, and start by [DRAFTING] an index like this: 

Document Name = [ Geographic level-of-care ] + [ Setting ] + [ Role ] + [ Name of note ]

Where :
  • Geographic Level-of-care = Where the patient is registered, e.g. Inpatient or Outpatient,
  • Setting = What unit the patient is registered in, e.g. Med/Surg, Cardiac Telemetry, ICU, Childbirth, Nursery, Pediatrics, Psych/Behavioral Health, etc
  • Role = Role of the documenter, e.g. Adult Hospitalist, Pediatric Hospitalist, Intensivist, ED Nurse, ICU Nurse, Med/Surg Nurse, etc.
  • Name of Note = Common name of note, e.g. Admission H&P, Daily Progress Note, Discharge Summary, Consult Note, etc.
So, for example, you could use this naming convention to design a document index like this :
  • Inpatient - Med/Surg - Adult Hospitalist - Admission H and P
  • Inpatient - Med/Surg - Adult Hospitalist - Daily Progress Note
  • Inpatient - Med/Surg - Adult Hospitalist - Discharge Summary
  • Inpatient - Med/Surg - Adult Hospitalist - Medical Consultation
  • Inpatient - Med/Surg - General Surgeon - Admission H and P
  • … etc…
The reason I would probably avoid specialty, and instead use role, is because some specialties fill multiple roles (e.g. Med/Peds specialists might work one day in the role of an Adult Hospitalist, and the next day in the role of a Pediatric Hospitalist) - 
So if you decide to use this format, then, the strategic question will become : What exactly is your organization's list of roles? 
  • The more roles you have, the more expensive it will be to maintain your documentation, but the happier your docs will be having documentation designed just-for-them, and the easier it will be to collect role-specific quality indicators.
  • The less roles you have, the cheaper it will be to maintain your documentation, but your docs may not be as happy having to accommodate to a one-size-fits-all approach, and the harder it will be to collect role-specific quality indicators.
So you will need to strike some sort of balance between the two. On the most cost-effective, conservative side, you might have very generic roles like : 
  1. Inpatient - Med/Surg - Attending - Admission H&P
  2. Inpatient - Med/Surg - Attending - Daily Progress Note
  3. Inpatient - Med/Surg - Attending - Discharge Summary
  4. Inpatient - Med/Surg - Consultant - Consult Note
And in the happy-medium, make-the-docs-happier and collect-more-role-specific-quality-indicators range, you might have roles like : 
  1. Inpatient - Med/Surg - Adult-Hospitalist - Admission H&P
  2. Inpatient - Med/Surg - Adult-Hospitalist - Daily Progress Note 
  3. Inpatient - Med/Surg - Adult-Hospitalist - Discharge Summary
  4. Inpatient - Med/Surg - Adult Hospitalist - Consult Note
And finally, on the most-expensive, docs-might-love-it-but-nobody-can-afford-it side, you might have roles like : 
  1. Inpatient - Med/Surg - Adult-Hospitalist - Dr. Stanley - Admission H&P
  2. Inpatient - Med/Surg - Adult-Hospitalist - Dr. Stanley - Daily Progress Note 
  3. Inpatient - Med/Surg - Adult-Hospitalist - Dr. Stanley - Discharge Summary
  4. Inpatient - Med/Surg - Adult Hospitalist - Dr. Stanley - Consult Note
For provider satisfaction reasons, I generally wouldn't recommend the first approach, and for cost reasons, I generally wouldn't recommend the third approach. Naming conventions and document indexes with provider names means you will be spending a lot of time and resources maintaining a much larger set of order sets or documentation than you might have budgeted for.

Whatever strategy you decide to employ, you will be living with the decisions for a long time, so I recommend really spending some time, drafting your naming convention and documentation index, and present it to both your clinical and administrative leadership for approval, before moving forward.

Hope this helps! Good luck!

- Dirk :)


So gradually, you start to learn how these tiny, seemingly trivial design details impact the cost of care and maintenance of your EMR, and so you look out for them and look for ways to help cut costs and still maintain provider satisfaction. 

Please note : Other responses to this question included recommendations about using LOINC coding standards to assist with developing industry-standard file naming conventions. This is great advice, and helpful in achieving documentation harmony, especially if you are planning on a HIE or exchanging documentation with other organizations. You can read more about LOINC by going to their web page :

Anyway, this was just a very basic introduction to some EMR design issues, and how they impact the cost of EMR maintenance - but I hope this story will be helpful to you in tackling your own naming convention and documentation indexing challenges!

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