Physician Documentation a Welcome "Epidemic" at Prince William Health System

Bonnie Seekford can be very persuasive. Lately, however, the clinical analyst at Prince William Health System (Manassas, VA) has found she doesn't need to convince physicians to use MEDITECH's Physician Documentation: they're coming to her to request it. "Physician Documentation is contagious, like a virus," says Seekford. "As soon as a physician sees a colleague documenting on-line, he or she has to have it, too."

Throughout the 170-bed, nonprofit hospital and affiliated practices, physicians find documenting on-line saves them time, once they adapt to the new workflow in a week or two. Prince William's pediatricians and pediatric hospitalists have been so successful using Physician Documentation they've actually mandated on-line progress notes within the next six months. These physicians are on target to meet their goal of a more comprehensive Enterprise Medical Record (EMR).

Below, Seekford and Director of Clinical Applications Kim Van Duyse discuss their success with Physician Documentation and explain the steps they took to guarantee physicians' first experience with documenting on-line was both comfortable and encouraging.

MEDITECH: Prince William licensed the EMR and Provider Order Management (POM) eight years ago, before Physician Care Manager (PCM) was available. How would you describe adoption/usage of these two components when you first implemented the software?

Bonnie Seekford: Physicians took to the EMR from the start, and now their usage is up around 90-95% percent. I would have to describe them as very EMR-centricthey use it in the office and at home, too. But even though physician usage is high, Prince William still maintains paper charts. Clinicians have the option to print results and reports, even though the information is accessible in the EMR. Nurses have had a harder time letting go of paper, thus CPOE orders automatically print out on blue paper so the nurses are sure to see them.

Right now, CPOE usage for physicians is at approximately 17%, but we hope to increase it by 15-20% when we add POM in the Emergency Department next year. We've been LIVE with the Emergency Department Management (EDM) tracker for two and a half years now, and plan to pilot Physician Documentation, Ambulatory Order Management (AOM) and POM in the ED's pediatric unit this month. We'll then roll out the components in the main ED throughout the rest of the year. It'll be a challenge, because we're in the process of opening a second EDin an outpatient clinic 10 miles west of Prince William Hospitalon July 1st.

MEDITECH: When did you decide to license Physician Care Manager (PCM), and what role did the Physician Documentation component play in that decision?

Kim Van Duyse: Prince William licensed PCM in 2000, but we've only focused on documentation within the last six months. We held off for a while, because Prince William Health System might merge with another health system in the area. Previously, our attitude was to put major projects such as implementations on hold, but administration has stopped doing that. They've decided to keep moving forward, because the flow efficiencies gained with documenting on-line were enough to make the change, if only for six months to a year. At this time we have a three-year plan in place and will take it from there.

MEDITECH: Did you use a third party, such as an outside consulting company, to assist you with implementation or physician adoption?

Seekford: No, we did everything in house.

MEDITECH: Does Prince William have a physician adoption committee, physician champions, dedicated staff, or another structure in place to address physician usage?

Van Duyse: Yes. Prince William's physician advisory group meets once a month and is headed by the director of medical informatics, Dr. Steve Tang. He participates in weekly conference calls with the clinical apps group to discuss templates and physician input. One or two physicians from each specialty provide feedback on the templates and their content, which they've solicited from their colleagues. The I.T. department then builds the templates. In addition, the I.S. department attends each department's monthly or bi-monthly meetings for physician feedback. Once the physicians reach a consensus, the I.S. department builds a standardized template. If the majority of physicians want to make a change to the template, the I.S. department will go ahead and edit.

From the start, our philosophy regarding documentation has been to keep things simple. Once the physicians are able to tackle the basics, they can come to us for additional functionality when they're ready for it. That way, we don't lose them at the very beginning because they're turned off by the feature's complexity. We're more likely to get their buy-in if we don't overwhelm them with everything first. We want physicians to be comfortable using Physician Documentation and feel a gradual approach works better.

Seekford: In addition to the physician advisory group, we have a physician champion, Dr. Steve Tang. Our CMO is Dr. Rich Travers. They work closely with all the physicians, but particularly focused on those who initially weren't as positive about the system.

MEDITECH: How did pediatrics come to be your pilot unit for Physician Documentation, and when did they go LIVE?

Seekford: The pediatricians were already using POM pretty extensively and asked for Physician Documentation. Thirty pediatricians, including pediatric hospitalists, have been using on-line documentation since the department went LIVE in February. They're doing great with the progress note template and love using it. In fact, at the last department meeting, the pediatricians voted to mandate that all progress notes be documented electronically within the next six months.

Van Duyse: Bonnie took a unique approach to documentation. She looked at the EMR and determined what physicians were missing; although they could dictate H&Ps and discharge summaries to store in the EMR, they didn't have daily progress notes. We created a basic SOAP note template, by specialty. Now, physicians have access to everything in the EMR.

MEDITECH: When you created that first progress note template in the pilot unit, did you base it on paper forms the pediatricians were already using?

Van Duyse: No, but we probably will base the ED template on paper forms and modify it for use on-line.

MEDITECH: Would you describe your template as an even mix of discrete data and free text?

Seekford: Yes, I'd say it's an even mix. The system automatically imports vital signs and lab results, and automatically recalls the last note. The physician exam is driven by queries, but they have the ability to enter additional information as free text.

MEDITECH: How did you train physicians to use the documentation component? Did you offer one-on-one training sessions? Were super users available to help, if necessary?

Van Duyse: We provided one-on-one training at the go-LIVE, because physicians didn't want to learn it until they really needed it.

MEDITECH: Cardiology, pulmonary, and gastroenterology are Prince William's most recent departments to go LIVE with Physician Documentation. How are things going so far?

Van Dyse: Now they're going great. Physicians were a little discouraged during the first week, because they needed some time to become familiar with the template. However, within three weeks they had a complete turnaround and now love it. They find it now saves them time.

Seekford: I compare documentation to a virus: a physician wants to use it as soon as he or she sees a colleague using it. And the more they use it, the more they want to use it. I was in the critical care unit recently, training a new physician to use documentation, when a cardiologist came over and said, "Bonnie, I absolutely love it!" The cardiologist's endorsement convinced the physician to give the documentation component a try. Naysayers tend to come around fairly quickly, especially when they see others documenting on-line. Once they learn what the queries and the normals are, they find the template is easy to use and saves them time. The challenge is they have to acclimate to entering information electronically rather than writing it by hand.

MEDITECH: What types of devices do your physicians use?

Van Duyse: Our physicians use desktops and computers on wheels (COWs), and we plan to pilot tablets in the ED. Very few of our clinicians document directly at the bedside. They prefer to focus on the patient during rounds and document the information afterwards.

MEDITECH: Are there any lessons learnedpositive or negativefrom your experiences so far you feel would be beneficial to another organization starting their Physician Documentation implementation?

Van Duyse: If we were to do it all over again, we wouldn't start the regular roll-out with cardiology, pulmonary, and gastroenterology. These specialties include some of the most complicated patients. Combined with a heavy patient load of 15 to 20 people per day, ranging from critical care to step down, we weren't able to train these physicians on documentation during rounds. Specialists who tend to care for more complex patients would be better to train right before go-LIVE, for example lunchtime training sessions at their offices. In hindsight, I would recommend beginning the regular roll-out with physicians who tend to have less complicated patients such as family medicine.

MEDITECH: Are there any particular factors specific to your situation you feel enhanced or hindered electronic documentation at Prince William?

Van Duyse: There's definitely strong support for a true electronic record. Our nursing and ancillary departments had already seen the benefits of documentation such as improved quality, so we knew it was the right thing to do. Communication among entire care teams has improved, and clinicians can access the EMR anywhere for the patient information they need. They don't have to hunt down or wait for a chart.

Our main hindrance is limited I.S. resources, which has forced us into a slower timeline than some anxious physicians would like.

MEDITECH: Finally, could you tell us a little about your plans for the future?

Van Duyse: We'll continue to roll out the progress note to all specialties. In the following year we'll be working hard to more fully automate the ED. We plan to introduce a unique progress note template to ED physicians in April, and hope to roll out CPOE before the end of the year. Also, we're considering using ED as our pilot for speech recognition in 2009.


Medical Information Technology, Inc.
Westwood, MA 02090