Dr. Daniel Ngui (biography and disclosures) Disclosures: Speaker and editor for UBC CPD. National Advisory Boards/Speakers Bureau: Amgen, Astra Zeneca, BMS, Bayer, BI, Lilly, Novo Nordisk, Sanofi, Aralez. Grants from: CHRC, CCRN, Bridge Medical Communications MD Briefcase, Medplan, Liv Agency, Four Health Communications, Science and Medicine Canada, Antibody Communications. Grants for EMR Projects: Amgen, Lundbeck, Astra Zeneca, BI, Pfizer, Merck. Investments in Heath Choices First. Clinical trial: Simple Trial, Amgen 20170191 trial, CV Care. Mitigating potential bias: recommendations in this article are unrelated to products/services/treatments involved in disclosure statements.
Special thanks to my colleagues working in the PPEP program for their contributions: Dr. Nikki James, Dr. Eva Knell, Ms. Nadya Castro, Dr. Kathryn Fung and Dr. Michael Murray!
What I did before
I’m very fortunate to have already had two different careers in medicine. Early in my career, I worked as a family physician with a service contract where I was able to develop my medical and communication skills by providing team-based care to a focused group of patients who were medically complex, housebound, and/or medically frail. I could focus on the clinical issues as the operational and practice management issues were managed by the local health authority clinic managers. A decade later, after I was asked to take over for a retiring community family physician, I am now immersed in the pressures of a fee-for-service environment (FFS) with an entirely different (daunting) workload with additional practice management issues. Thankfully, I had my past experiences and time to develop my clinical and communication skills to be able to attend to patients’ needs more effectively. Now, although I still try to be as efficient as possible, I can still attempt to practice the art of medicine.
My way of coping in a FFS environment was to explore the use of team-based care, technology (such as voice dictation), and focus on optimizing our electronic medical record (EMR) to improve medical documentation and panel/roster management. These ideas were put to the test when it came time for me to have my own Physician Practice Enhancement Program (PPEP) assessment by the College of Physicians and Surgeons of British Columbia (CPSBC). It was both an eye-opening and practice-changing experience. I had a lot to learn.
What changed my practice
I recall my own feelings of uncertainty and consternation about “why and what” happens during a College PPEP assessment. As the medical director for the clinic, I had to prepare our medical office staff, ensure our office policies and protocols were up to the College standards, and provide some guidance to our clinic physicians.
Dr. Ezekiel’s 2012 article helped me understand the process and rationale for a PPEP assessment: https://thischangedmypractice.com/practice-review. His key message was that good medical documentation affirms our pledge to patient care and is part of our commitment to lifelong learning and improving. He wrote about the office assessment process with reviews of the clinic’s emergency equipment, sharps containers, and autoclave equipment. I remember searching the College’s website for the PPEP assessment standards (https://www.cpsbc.ca/programs/ppep) and reading the Physician Office Medical Device Reprocessing standards (POMDRA) and resources. It was helpful for myself and my office manager to lookup information on medical device reprocessing (MDR) for community-based physician offices (https://www.cpsbc.ca/programs/pomdra/mdr-faqs) to prepare for our clinic’s PPEP assessment.
My personal experience is that we as physicians, set high standards for ourselves and often have a black/white or good/bad mentality, which is not the intent of the program (https://www.cpsbc.ca/for-physicians/college-connector/2019-V07-02/08). The outcome of my assessment was far from perfect and yet I received some great suggestions on how improve my practice and the clinic. I genuinely felt my assessment was useful as a continuous, lifelong learning experience… and the experiences shaped my career directions!
What I do now
Fast forward to the present, still in the trenches of FFS primary care, facing daily clinical and practice management demands and every increasing burden of EMR documentation, I decided I had to learn more, and applied to become a PPEP medical advisor. Now, after one year as a medical advisor, I can share my first-hand experience and perspectives of being on both “sides”.
What I’ve learned is that the intent of PPEP is educational and focused on helping physicians enhance the quality of their patient care through a peer review. Being “behind the scenes”, I see a systematic process that has shifted from a quality assurance approach to a quality improvement approach.1
I see a dedicated team of College staff, physician medical advisors, and community-based peer medical assessors, who want to provide specific feedback to help improve care to medical directors and individual physicians.
Although initially many physicians feel it is an intimidating endeavor, the community-based peer assessors simply provide feedback based on a review of:
- Site interviews (physician and staff),
- Medical records,
- Provincial PharmaNet prescribing profile, and
- Feedback reports (self-assessment plus feedback from patients, co-workers and medical colleagues)
Next, a “Performance Review Action Plan” (PRAP) letter is prepared at the College by a team of staff and medical advisors to highlight areas that one could consider improving. As medical advisors, we strive for a holistic approach to understand the background of each physician and look at multiple areas of the assessment to provide specific suggestions in a form of a letter or a phone call to assist the clinician to identify priority areas to improve medical record documentation and clinical practice.
Although this process is a large investment, it is a requirement of our College to self-regulate and these assessments can prompt medical directors and community physicians to make positive changes in order to meet the PPEP Assessment/College Standards. In many instances, physicians appreciate the advice given during interviews, as well the PRAP letters which provide suggestions about how to improve medical documentation and policies, which ultimately enhance care. All community-based physicians (family physicians, dermatologists, general internists, psychiatrist and pediatricians) will eventually have a PPEP assessment.
Just as clinical medicine has changed, so have the expectations for communication, documentation, and practice management. What was taught in medical school years ago is not the current standard. There are many reasons for clinicians to keep a detailed medical record. First, it is to simply provide a record of the encounter and to improve communication amongst medical colleagues. Next, we know that documenting an assessment and differential diagnosis in a clinical note, as well as adding to the longitudinal Cumulative Patient Profile (CPP) is an important reflective process that supports clinical reasoning. The process of reflective documentation can help clinicians avoid “premature closure” or jumping to conclusions without considering a wider differential. Properly completed medical records can also help one meet the MSP and CMPA requirements for adequate documentation. The bottom line is that achieving good medical documentation standards can help mitigate risk on many levels.
What can you gain from this article?
First, consider this simple self-reflective test. Review a random clinical note and see if it adequately answers the following:
- Does the documentation of the clinical encounter answer the 3W’s? “Why the patient presented…? What was found? What was done about it?”
- Can another clinician – who may have to take over your patient’s care – efficiently and effectively understand your train of thought (“intellectual footprint”)? Is there adequate documentation of the HPI, the pertinent positives and negatives in the history and physical exam? Can another clinician read the medical file easily and identify the provisional and differential diagnoses, the treatment, and follow-up plans? Can another physician look at the CPP and understand the biological, psychological, and social factors that may affect the patient’s longitudinal care?
Second, review the BC College PPEP Unified Medical Record Assessment Standards: https://www.cpsbc.ca/files/pdf/PPEP-AS-Unified-Medical-Record.pdf given recent trends to move towards physician group practices and some adopting more team-based care, a process to review one’s charts and knowledge.
Finally, one can consider other novel techniques to improve patient care and documentation.
- To improve medical record documentation one can:
- Use a medical scribe in practice2,3. A medical scribe is an employee with medical training (in my case an International Medical Graduate – IMG) who helps one document and prepare paperwork, labs, and referrals while I see the patient in the room.
- Use electronic medical record “macros”4,5 or shortcuts for templates to populate in the EMR. These macros can be helpful as long as the templates are actually individualized to reflect the clinical encounter and populated with data collected during the visit. Anything not covered during the visit, should be deleted from the macro, so the visit note truly reflects what happened during the visit.
- Voice Dictation6,7. A family physician colleague at my office said the single best thing he did (above and beyond the EMR) was to adopt voice-activated dictation to improve his documentation which enabled him to have more personal time at home. Dictation in the clinical encounter can be helpful for educating patients, as well as reducing the time required to document (during or after seeing patients) and improving the record of clinical details and care plan without increasing one’s workload as no one can type as fast as you can dictate.
- To improve clinical practice one can:
- Utilize EMR dashboards8,9 to understand our practice rosters and develop registries of patients with chronic disease. Assign staff or designate a chronic disease coordinator who can be delegated to review clinical dashboards to identify care gaps.
- Utilize standardized protocols and chronic disease templates and/or flowsheets10,11,12 to efficiently document chronic disease care provided. EMR vendors can help clinicians with these tools to ensure that the latest medications, lab reports, and data are automatically populated into the flowsheet. This can then make practice reflection and clinical care decisions more efficient.
Certainly, as a physician still striving every day to get it right, I am confident I’ll never have it perfect. Through the process of quality improvement and along the theme of lifelong learning, the College’s PPEP offers physicians in BC a way to improve patient care. It’s not a pass or fail, but rather it’s the process of improvement that matters.
References
- Larson DB, Nance JJ. Rethinking peer review: what aviation can teach radiology about performance improvement? Radiology. 2011;259(3):626-632. DOI: 10.1148/radiol.11102222. (Request with CPSBC or view with UBC)
- Bossen C, Chen Y, Pine KH. The emergence of new data work occupations in healthcare: The case of medical scribes. Int J Med Inform. 2019;123:76-83. DOI: 10.1016/j.ijmedinf.2019.01.001. (View with CPSBC or UBC)
- Pearson E, Frakt A. Medical scribes, productivity, and satisfaction. JAMA. 2019;321(7):635-636. DOI: 10.1001/jama.2019.0268. (Request with CPSBC or view with UBC)
- Knight MJ. Make medical notes better and faster with macros. Fam Pract Manag. 2005;12(8):42-44. (View)
- Roman-Belmonte JM, De la Corte-Rodrigeuz H, Rodriquez-Merchan EC. Comparative analysis of two methods of data entry into electronic medical records: A randomized clinical trial (research letter). J Eval Clin Pract. 2017;23(6):1478-1481. DOI: 10.1111/jep.12835. (View with CPSBC or UBC)
- Johnson M, Lapkin S, Long V, et al. A systematic review of speech recognition technology in health care. BMC Med Inform Decis Mak. 2014;14:94. DOI: 10.1186/1472-6947-14-94. (View)
- Hodgson T, Coiera E. Risks and benefits of speech recognition for clinical documentation: a systematic review. J Am Med Inform Assoc. 2016;23(e1):e169-179. (View)
- Clarke S, Wilson ML, Terhaar M. Using dashboard technology and clinical decision support systems to improve heart team efficiency and accuracy: review of the literature. Stud Health Technol Inform. 2016;225:364-366. DOI: 10.3233/978-1-61499-658-3-364. (View with CPSBC or UBC)
- Dowding D, Randell R, Gardner P, et al. Dashboards for improving patient care: review of the literature. Int J Med Inform. 2015;84(2):87-100. DOI: 10.1016/j.ijmedinf.2014.10.001. (Request with CPSBC or view with UBC)
- Terasaki J, Singh G, Zhang W, Wagner P, Sharma G. Using EMR to improve compliance with clinical practice guidelines for management of stable COPD. Respir Med. 2015;109(11):1423-1429. DOI: 10.1016/j.rmed.2015.10.003. (View with CPSBC or UBC)
- The College of Family Physicians of Canada. Use of chronic disease management tools. Canadian Family Physician. 2011;57(12):1423. (View)
- Weyer SM, Konrad N, Esola D, Goodwin MA, Stange KC, Flocke SA. Features of medical records in community practices and their association with preventive service delivery. Med Care. 2005;43(1):28-33. (View with CPSBC or UBC)
More info:
https://www.cpsbc.ca/programs/ppep
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I see no virtue in the QI as opposed to QA approach. None of us would be here if we didn’t start out as caring about excellence. We have a degree that’s considered a doctorate because we’ve achieved a level of professional competence as well as the ability to understand how to maintain it. Those who cut corners to get rich or are losing their abilities need to be dealt with, not simply encouraged along with everyone else to improve a few points so the median goes up.
I see no virtue in having individuals trying to increase the median documentation performance by each taking their performance up ten percentile points in hopes everyone will improve the same amount and the median will increase by ten. Why should the adequate and stellar ones increase? Will the need to improve in this one particular way ever stop? How can it if we refuse to define adequate?
As a doctor I want those ‘poor performers’ who rush through and don’t document for financial reasons to have a disincentive to behave that way so I don’t have to hear any claims that there’s no problem with FP remuneration, or to have a WIC owner not want to give me shifts because I’m not a similar poor performer. Likewise as a patient, I don’t need to know that most docs including poor performers are encouraged to be just a bit better so as to raise the median performance. I want to know that poor performers are being dealt with so I am not their unknowing victim. Sometimes it is decline in ability and simple encouragement will not get them to adequate, though requirements to address the cause may. But if it’s lack of concern than that can only be dealt with by threats.
Also I hope you are not correct and that population health is the next thing they will use to define quality. We are medical experts, not public health experts, and the practice of medicine is an art in dealing with individuals. One thing I’ll never do is exaggerate the benefits of a test or treatment to my patients in order to meet my goals. Nor as a patient do I want to have a College or a government administrator dictate to my doctor what the goals are. It should be helping me meet mine.
Although this would seem to apply to family practice I think a lot applies to specialist physicians. Sharing EMR data with your colleagues can be invaluable as we share the care of so many patients. It can be very difficult to achieve as many physicians prefer to do their own thing.
Thank you for your honest and heartfelt comments!
In reflecting on what you are communicating, I am interpreting that you feel that physicians should be self-regulating and as professionals, oversee directed self-learning and strive for our own quality improvement and control. I agree wholeheartedly with your statements.
What you desire and what the intent of the BC College of Physicians and Surgeon’s Physician Peer Enhancement program is, are one in the same. The quality improvement process is about reminding all doctors of your pursuit of self-directed learning and professionalism as not all physicians have dedicated the same amount of time and effort you have invested to improve your clinical care and your practice.
In my opinion, it is certainly not a college assessor or BC government official dictating how care should be delivered. It is simply a systematic process of experienced peer medical assessors in the same specialty area, along with a second opinion of medical advisors with clinical experience who provide a holistic approach to provide recommendations to improve practice whilst ensuring that safe patient care is the priority.
This Changed My practice is a vehicle to share ideas and comments. I hope I have conveyed in my article, I certainly am not claiming, I’ve figured it out. I’ve stated I still a lot to learn. I have offered to share with the medical community some observations and thoughts that might help others. I realize my suggestions may not be for everyone, and many physicians may have different interpretations.
Although not explicitly mentioned in the article, my definition of population health management is using team-based care and the power of the electronic medical record to help improve individualization of care. I am excited that one day, we can use EMR queries and tools to identify care gaps that we as physicians and human being may have missed. It is certainly not about exaggerating tests or benefits but about having individual conversations with our patients, so we can do what we do best, which is be medical experts and provide advice based on our longitudinal and continuous knowledge of and relationships with patients.
As to your points about what you may have observed or assumed about your medical colleagues in the community, the “poor performers’ who rush through and don’t document for financial reasons” and your concerns for patients, “…Likewise as a patient…I want to know that poor performers are being dealt with so I am not their unknowing victim.”
First, there is a process to help physicians who are struggling with balancing the practice management issues, documentation requirements and clinical demands. This process allows the PPEP program to identify and offer recommendations with a series of escalating interventions to ensure safe patient care, if required and appropriate.
Second, the physicians who you mention rush and don’t document for financial reasons have a different authority to contend with, the MSP audit system which is beyond the scope of my article, but another system that may deal with your concerns.
Once again, thanks for your comments.