Sanford Health is one of the largest health systems in the United States. Headquartered in Sioux Falls, South Dakota, the organization includes 46 hospitals, 1,400 physicians and more than 200 Good Samaritan Society senior care locations in 26 states and 10 countries.

THE PROBLEM

Providers at Sanford Health had for years been sharing feedback that a lot of the information in the note section of the EHR was not necessarily useful for the person reading the notes. For example, no one wants to review blood work in the notes. That would be better viewed in results in the patient's chart.

"But the biggest concern we heard from providers was that they would have to scroll through pages and pages of information to get to the assessment and plan section they were looking for, which were always at the very end," said Dr. Roxana Lupu, chief medical information officer at Sanford Health. 

"To illustrate the challenge, one provider scrolled through what ended up to be a 19-page printed document to get to the information she needed in one paragraph on the last page of the note."

There also were complaints about how information is organized differently by each note author, and how note readers have to adjust to so many individual templates. One ask that Lupu heard repeatedly from clinicians was a similar look and feel for all notes.

PROPOSAL

"The feedback we received from our providers prompted us to review what was at the crux of the note bloat problem and create a standardized note in the Epic EHR to improve the provider experience," Lupu recalled. 

"It was important to keep in mind that providers were not only writing the note for themselves but for others. We wanted the assessment and plan to be the most prominent part of the note, as that was the reason for reviewing notes."

"The biggest concern we heard from providers was that they would have to scroll through pages and pages of information to get to the assessment and plan section they were looking for, which were always at the very end."

Dr. Roxana Lupu, Sanford Health

Sanford Health designed a standardized note template that encourages providers to document everything they need to – and nothing they don't. It started from the basic principle that a note is a form of communication to other providers and patients, and not a review tool for the note author.

"The standard templates do not contain any links to import lab or imaging results, or any information that can be found anywhere else in the chart," Lupu explained.

"Healthcare providers review others' notes to see their impression and plan. We rearranged the note templates to display the assessment and plan at the top of the note, reducing scrolling, therefore reducing the time spent reviewing notes."

Also, the subjective and objective portions of the note are collapsed by default, so providers are more likely to focus on the plan and the assessment that are displayed at the top.

MARKETPLACE

There are many vendors with electronic health records systems on the health IT market, including Allscripts, athenahealth, Cerner, DrChrono, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.

MEETING THE CHALLENGE

Practically speaking, the standardized and revamped note format has made it easier for providers to document what's important, and not focus on importing and editing information that can be seen in other places in the chart, Lupu said. 

The provider now is incentivized to address and maintain the problem list, an important part of a patient's record, which often is put aside because it is considered double work, she added.

"We also encourage our patients to contribute to the note," she said. "During the e-check-in process, they are asked to enter a short summary in MyChart about events from their last appointment and concerns they want addressed during the visit. 

"This information is imported into our standard notes, helping providers set an agenda for the visit and empowering patients to take an active part in their healthcare, while at the same time reducing the documentation burden for providers," she explained.

Speed buttons for the standard templates were added to all navigators to make it easier for providers to select the right template more easily, eliminating the extra clicks required to import templates.

"Having standard templates for our notes allows us to make changes to meet regulatory and compliance requirements," Lupu noted. 

"For example, when documentation requirements changed as part of the E&M codes overhaul in January 2021, we quickly made adjustments to our standard templates to reflect those changes. This was another selling pitch for our standard notes, as providers saw the benefit of having those templates automatically adjusted for them, as opposed to spending time modifying theirs."

RESULTS

Primary care specialties, like family medicine and internal medicine, are the heaviest users of the Sanford Health-created standard notes, with 42% of notes generated by family practice providers and 52% of notes generated by internal medicine providers being standard notes.

Based on Epic Signal data, which keeps track of EHR utilization like time in notes, length of notes and more, both specialties now have short, efficient notes, with time in notes and note length below Epic's overall average.

ADVICE FOR OTHERS

"It is important to cater the technology to whatever providers want and to design a program based on their feedback," Lupu advised. "Our providers wanted to see other providers' impression and plan, and they wanted consistency with same look and feel for the notes.

"Reducing time spent documenting, as well as time spent reviewing notes was a huge ask," she concluded. "Less time spent in notes, and more time spent with the patient, was our main goal when designing and maintaining the standard templates."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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