UW Medicine includes 3 hospitals, University of Washington. Medical Center (UWMC), Harborview Medical. Center (HMC) and the Seattle Cancer Care Alliance.
The Physical Attractiveness of Electronic Physician Notes Thomas H. Payne MD, Rupa Patel MSI, Sally Beahan, RHIA, Jacquie Zehner RHIT University of Washington Seattle, Washington ABSTRACT Though notes in electronic medical record systems (EMRs) have advantages, they are often criticized for their unattractive and unprofessional appearance. We sought to identify notes regarded by physicians as attractive and unattractive and the characteristics of both. We sent a sample of 10 notes representing a variety of common note types to a sample of 70 physicians who are either leaders in UW Medicine or randomly selected note authors and asked them to rank the notes by their physical attractivness. We found their rankings were not random, and notes clustered into those considered most, intermediate, and least attractive. Characteristics of each group are presented. We’ll use these results to format EMR notes in a more attractive form—a goal important to our physicians—while preserving important clinical, quality and compliance features that were our original goals in moving to electronic notes. INTRODUCTION Though notes in electronic medical record systems (EMRs) have many advantages such as improved legibility and ease of access, EMR notes have been criticized for containing inappropriately copied and pasted text,1 poor readability2 and also for their unprofessional general appearance. While several articles have addressed copying and pasting, less attention has been devoted to how notes appear when printed or viewed electronically by other clinicians or referring physicians. Many physicians regard this to be an important matter, since notes are often transmitted to referring physicians in hopes they have a professional, attractive appearance. In the years since we began our transition to electronic records, many physicians have complained to us that while electronic notes have advantages they have generally declined in their appearance. Though attractive appearance is not the major goal of writing an electronic note, it is regarded as important by many and perhaps most physicians. The purpose of this study is to identify notes physicians consider to be physically attractive and unattractive and the characteristics of both, so that we can improve the
appearance of notes in our EMRs and when viewed by users of our EMRs and by physicans outside our institution. BACKGROUND Setting This project was undertaken as part of a quality improvement initiative of the UW Medicine Health Information Management Committee. UW Medicine includes 3 hospitals, University of Washington Medical Center (UWMC), Harborview Medical Center (HMC) and the Seattle Cancer Care Alliance (SCCA). In 2007, UWMC had 390 beds, 72 ICU beds, and 18,120 admissions; HMC had 369 beds, 73 ICU beds and 18,777 admissions. The SCCA has one hospital for adult patients, consisting of 18 beds. All three hospitals serve as teaching hospitals for the University of Washington. There are 792 active hospital medical staff UWMC, 492 at HMC, and 297 at SCCA. Across all hospitals there are approximately 1,000 residents and fellows, 826 medical students 1,610 full-time and 1,182 part-time nurses. Outpatient care is provided in hospital associated clinics, 2 emergency rooms and 7 UW Neighborhood Clinics. Collectively these clinics and emergency rooms provide approximately one million outpatient visits annually. How notes are written in our EMRs Several EMR systems are used in UW Medicine. For inpatient care and most clinics, Powerchart (Cerner Corp.) is used for creation and storage of electronic notes.3 In some clinics, EpicCare (Epic Systems) is used. In operating rooms, Docusys is used for physician documentation. Physician notes created in Powerchart or EpicCare are created using a variety of techniques, including templates, direct typing of narrative text notes, voice recognition software, (predominantly Nuance Dragon Naturally Speaking), and by dictation with professional transcription. The method used is determined by physician preference and local policies. To reduce transcription costs, physicians have been encouraged to reduce use of dictation but in most care settings dictation is permitted. Dictation is used less often for inpatient
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care because of the need for rapid note availability. Templates used are created both by individuals and by information technology support personnel. All templates are reviewed by the professional fee compliance department except those created only for individual use. Template standards are proposed and loosely enforced by a variety of local committees; in practice, because of the rapid growth in electronic note use there is wide variation of template style. A proposal to standardized template overview in a high level committee is being reviewed by the Health Information Management Committee. Each day, roughly 1,500 inpatient electronic notes and 2,000 outpatient notes are created by resident and attending physicians. METHODS We asked 70 physicians to participate in this study. Forty are physician leaders in UW Medicine drawn from committees overseeing our medical record or with developing administrative and clinical policies for our hospitals and clinics, and 30 were randomly selected from a list of physicians who recently wrote notes in our EMR systems. All participants are clinically active in our academic medical center, and many maintain close professional relationships to referring physicians. We used 70 physicians for logistical rather than sample size considerations. The authors selected 10 notes from among the most common note types used in our EMRs. These are clinic notes, inpatient progress notes, and consult notes. From these note types, we selected notes that in our opinion reflected a spectrum of physical attractiveness when viewed in printed form, understanding that our judgement may differ from that of others. These notes were created using different EMR systems, and within each EMR system using a variety of technicques. Each of the notes was manually reviewed and any text that could be used to identify a patient or provider was obscured by editing or using an opaque ink marker. This sample was representative of the notes contained in patient records created in UW Medicine. We sent each physician these ten notes in random order in an envelope. Along with the collection of notes we sent a cover letter with the following instructions: “In the envelope with this letter you will find ten notes. Lay these on your desk, and sort them with the note you find to be the most attractive in appearance on the top, the note that is least attractive on the bottom, and with the other 8 notes sorted from most attractive to least attractive in between. For purposes of this study, do not consider
the content of the note, but rather how attractive it appears when viewed by UW Medicine and referring physicians. When you are done, put the sorted stack in the enclosed envelope and mail it back to me via interdepartmental mail.” We included a card redeemable for five dollars of coffee as compensation for participating in this study. A separate sheet was included to track completion of the task. No identifier linked the returned stack of notes to an individual physician participant. We recorded the sequence of notes in the returned envelopes, and assigned rank of 1 to the first note, 10 to the last note, and 2-9 to the notes in between. We summed the rankings assigned by all physicians to each note. We tested the null hypothesis that physician ranking of attractiveness for the 10 notes could be explained by chance alone, using the Kruskal–Wallis one-way analysis of variance by ranks. The level of significance threshold was 0.05. Note characteristics. Before ranking results were received, we created a list of characteristics that distinguished the notes from each other, shown in Table 1. The study was reviewed by the UW Human Subjects Division and deemed exempt from full review. RESULTS Of the 70 physician participants, 4 were unable to participate because they were no longer with UW Medicine or were on leave. We received stacks of sorted notes from 50 of the remaining 66 physicians invited to participate, a response rate of 76%. Figure 1. Physician rankings of attractiveness of notes. Bars indicate sum of rankings. Lower sums indicate higher ranked notes. X axis are note numbers. Using Kruskal-Wallis test we rejected the null hypothesis that physician ranking can be explained by chance alone, p
