How Does One Herd a Few Hundred Thousand Sheep?

Medicine is one of the most non-standardized industries. Pricing varies per carrier, region, and procedure, often by an order of magnitude. Before EHRs, every physician designed their own paper templates, and even in the EHR era, many doctors still use highly customized digital templates. Most laymen assume that medicine is a repeatable science, where there’s a best way to do things. Apparently not.

Although complete standardization is bad, the status quo is 0.1 percent standardized. Every doctor practices his or her own unique flavor of medicine. The ideal lies somewhere in between the two extremes. The benefits of more harmonious and coordinated documentation would be felt throughout the healthcare system: more effective training for residents, better communication among care providers, more efficient back-office work (i.e. coding and health information management), simpler audits, and maybe eventually patient readability.

How on earth are clinicians going to be trained to adopt better, more standardized documentation practices? They aren’t. I would pity the pour souls whose job it is to tell hundreds of thousands of doctors and nurses how to do something in the new "right" way (which implies that they’ve been documenting the wrong way.)

But what if there were a different way? What if clinicians didn’t have to be taught new documentation standards from an overlord? Could a change in daily behavior be driven through a bottom-up approach instead of top-down? What would the bottom-up approach look like? How would it work?

Peer pressure is perhaps the most effective behavioral change mechanism of all time. It has proven to be the single most effective lifestyle change to help people lose and keep off weight. What if clinicians pressured one another into better, more consistent documentation practices?

Richard Vaughn, MD recently posted a brilliant idea on the listserv for the American Medical Directors of Information Systems (AMDIS): let doctors rate the quality of other doctors’ clinical notes in the EHR on a five-point scale.

Every doctor would have a "documentation quality" score that would be viewable by all the other clinicians at the hospital. This would be a sensitive issue. It would need to be designed and presented in such a way that it’s not a rating of clinical care ability or quality, just a rating of documentation. The score should only be available to peers, not available to people who don’t share the same job role or to the public.

Or it could be gamed. It would be an interesting experiment nonetheless. Hospital management would learn a lot about bottom-up behavioral change mechanisms that could be applied to future initiatives. Perhaps companies that try to drive quality improvement changes, such as KaiNexus, could tap into it.


Kyle Samani is a healthcare technology entrepreneur who is passionate about healthcare and technology startups.

  • Steven Davidson

    As an AMDIS member I read this when it was first posted there. The concept for input is not bad, though my experience leading physicians is that one quickly sees compression with scores entered as 3-5 almost universally; a brief summary of what constitutes a 1-5 level note for each level and ready definition through on-screen popup could be helpful.

    The data, once collected, can’t simply be shown to each physician; the route to behavior change is more complex in my experience of leading physicians.Share the information privately for some period of time (~12 months) with each physician in a one-to-one meeting with a respected physician leader. Large hospitals will have a Department Chair/Division Chief; smaller hospitals perhaps only a Chief Medical Officer and Medical Staff President. These leaders, regardless of title and formal role must be prospectively engaged and must own the feedback process. It cannot come from IT or a CMIO–if it does it will fail. Simultaneously with the initiation of private feedback, provide coaching and formal training in documentation improvement. Continue regular feedback of individual performance and add peer results so the individual physician can see where they stand by percentile within their similar practice physician group. Good graphics help.

    Only after this ~12 month period should more general publication be considered.

    Kyle is correct, physicians are competitive, but they are at least as self critical as they are competitive. This is a social-psychology challenge, facilitated by health IT. Clinical leaders and their colleagues are challenged by the absence of actionable feedback generally in clinical practice. Documentation quality should be only one dimension of such feedback.

  • kylesamani

    Dr Davidson,

    Excellent points. The execution will determine the validity of the concept. You have to have the right people own the process to prevent such a system from destroying itself.

  • Kathryn Schlosser

    Dr Davidson and Kyle, I am sitting back thinking this is being made much more complicated than it has to be. Physicians are trained professionals, just as many of the other disciplines. Granted, some have to train more years, but that does not change the basic training that they all start out with, it just changes the ego and stratosphere. IT is not to blame for the comparisons. Perhaps one of the first tenets in medical school should be a reminder that “Everything I need to Know, I learned in Kindergarten” and that the patient is the reason we are all here.

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