Brian Jacobs, MD, is a pediatric critical care physician before all else. But there’s quite a lot to his “all else.”

As executive director at the Center for Pediatric Informatics and The Children’s IQ Network at the Washington, DC-based Children's National Medical Center, Jacobs is also the CIO and CMIO.

He got there the old-fashioned way: Pointing out a problem and asking that it be fixed.

“The ICU is a very toxic and tech-laden environment,” Jacobs says. And because of that, it offers the opportunity to make a lot of mistakes. And that worried him. So, Jacobs began to complain about it, and lo and behold, he was put in charge of fixing it back in 2008.

Since then, he’s learned a lot about getting the biggest bang for the buck from electronic health records, and one of the key things is getting the notes to be clutter-free. They may be electronic, but that doesn’t mean they are automatically easy to read. Far from it.

Jacobs says in a way, the ROI for EHRs is misleading, with odds seemingly stacked in their favor. On the plus side, EHRs are: more complete, legible, accessible and can be auto-populated and searched. They can provide diagnosis codes and they’re good for billing. On the other hand, they can sometimes lack quality information and are by far, too cluttered.

[See also: Who Writes Clinical Notes?]

Jacobs was determined to make EHRs more valuable, and that’s where what he affectionately calls his `one note per day per patient’ policy comes in.

Where does all the clutter and confusion in EHRs come from? And more importantly, how can it be eliminated? Here is some insight from Jacobs:

What to do about too many notes

It’s not uncommon in teaching hospitals to have six to seven notes per day on one patient, by the time the attending physician, residents, consultants, other doctors and fellows check on the patient. Before Jacobs instituted the requirement that all physicians add their notes to the same document, there was just too much information for any one clinician to wade through and find the latest on the patient’s care. In most cases, the frustrated and rushed clinician would end up not reading all the notes. If nothing else, this was downright dangerous to the patient.

“We wanted to cut down on volume of notes but still retain high quality,” Jacobs says of the one note program. “It’s actually one note per team per patient per day; one giant multi-contributor note. They still may be all writing their components, but it’s one note.”

First, the resident generates an electronic note from a pre-programmed template before rounds begin at 7:30 a.m. “The start is a resident’s note that is augmented by anyone who has something to augment at the end of the day. The resident discusses what’s in the note with the entire team, and amends it as needed.”

There have been requests to add nurses to the ‘one note,’ but so far that hasn’t happened, Jacobs says, though he admits it’s a good idea.

[See also: 'Note bloat' putting patients at risk.]

Cutting down on the clutter

Paper notes were 90 percent clutter-free; “people didn’t put gibberish in hand-written notes.” EHRs, on the other hand, have 60 percent clutter in them. “Clutter is stuff on the page with no value added to it,” Jacobs explains. Some is added information from auto-population. For example time stamps that go all the way to the seconds. The auto-populated terms for treatment and medications in electronic records is long and formal, not the shorthand style of paper notes. When you add a lot of this, there is a whole lot of unneeded, unwieldy information in the notes.

Jacobs tackled clutter by creating a scoring system for the notes that evaluated notes for completeness, readability, quality and clutter. He found that 60 percent of the EHR notes at his facility were clutter. Being aware of it, “we got better over time,” Jacobs says.

Physicians would have, for example, four complete blood counts in one day, with 20 results. “All of a sudden, you have 80 lines of data in the note,” Jacob says. “Some of this is under the control of the physician, and some of it is auto-populated by the computer.” 

Jacobs says he knows as a CIO he needs to allow some end-user flexibility around this. Some physicians prefer more expanded data than others, but he is already seeing some improvements in the look and feel of the note, with the added awareness the scoring has created.