Collaborative documentation

Collaborative documentation (CD) is an alternative paradigm for the documentation of healthcare encounters emerging as a potential solution for problems such as 'note bloat' and excessive documentation burden on providers.

Background

Usage of electronic health record (EHR) systems has become increasingly common in healthcare. The documentation paradigm in EHRs, however, mostly follows the common paradigm prior to their widespread use, the problem-oriented medical record and SOAP model developed by Larry Weed in the late 1960’s (1, 2). The technologic advances of the EHR allow copy paste (and copy forward) functionality, note templates, and dynamic text elements that pull data from other areas of the EHR, which are common in modern documentation (3). Over time, there has been an increase in size of notes in the EHR, often referred to as ‘note bloat’, as well as redundant information (4, 5). The translation of the SOAP note paradigm into the EHR may also lead to increase time spent on documentation (6). An alternative paradigm of collaborative documentation has emerged with the adoption of EHR and more recently has been suggested as a solution to some of the above problems

The idea of shared or collaborative documentation in the literature goes back to at least 2006, well after the development of EHR systems but before they became widespread (7). This was a forward thinking study looking at planning patient records to be used cooperatively for patient care and research. They proposed five steps as follows: “Analyze the prevailing documentation infrastructure, provide terminology management system (TMS), provide documentation management system (DMS), plan the logical architecture, provide all necessary tools” (7).

CD in psychiatry, therapy, and addiction research

Collaborative documentation has been researched in the fields of addiction, psychotherapy, and psychiatry (8-10). In these fields its focus has been on collaboration between provider and patient, with some evidence that it may improve treatment adherence (8). When examining attitudes, therapists desired flexible usage and felt it would benefit by providing a discussion framework, and patients felt it may improve communication (9). Finally, collaborative documentation has been suggested as a method of avoiding EHR and computer induced worsening of therapeutic alliance. One study (10) found that amongst providers, collaborative documentation had a negative correlation with the therapeutic alliance while amongst patients in the same group, there was a positive correlation.

CD, a new and evolving paradigm

In the last few years, several articles and perspectives have been written looking at collaborative documentation, or ‘wikify-ing’ clinical documentation, as a solution for issues with documentation in the EHR.

One perspective directly endorses the wiki model, which supports multiple authorship with version tracking, linkages, and APIs to promote interoperability (11). This model of multiple authorship would allow shared documentation amongst multiple members of a care team, without producing multiple fragmented documents. This would also allow error correction and continuous review, and potentially improve error propagation. Another suggested benefit is that wikis can use APIs to connect to external resources, using SMART on FHIR applications.

Another perspective suggests re-conceptualizing the entire chart in the EHR as a fully collaborative space organized by topic (12). Proposed benefits would be to provide a consolidated, accurate, and complete view of the ‘current state’ of the patient and make historical review simpler. The hope in this new paradigm is to improve efficiency and save time on data input and retrieval. This group has published a design and feasibility study (13) for an alternative model that avoids the single-author note paradigm. They show a database diagram and system based on ‘cards’ that are organized by topic for each patient. These can be problem based but also flexible enough to contain other unstructured data. Similar to the wiki concept, they would be able to be edited by multiple users, with version history and tracking, allowing changes to be viewed. They also propose different concepts such as workspaces for different tasks, chat functionality that is public facing and allow more urgent or real time conversations amongst multiple providers.

References

1. Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:593–600. 2. Wright A, Sittig DF, McGowan J, Ash JS, Weed LL. Bringing science to medicine: An interview with Larry Weed, inventor of the problem-oriented medical record. J Am Med Inform Assoc. 2014;21:964968.

3. Rule A, Goldstein IH, Chiang MF, Hribar MR. Clinical Documentation as End-User Programming. Proc SIGCHI Conf Hum Factor Comput Syst. 2020 Apr;2020:10.1145/3313831.3376205. doi: 10.1145/3313831.3376205. PMID: 33629079; PMCID: PMC7901830.

4. Steinkamp J, Kantrowitz JJ, Airan-Javia S. Prevalence and Sources of Duplicate Information in the Electronic Medical Record. JAMA Netw Open. 2022 Sep 1;5(9):e2233348. doi: 10.1001/jamanetworkopen.2022.33348. PMID: 36156143; PMCID: PMC9513649.

5. Rule A, Bedrick S, Chiang MF, Hribar MR. Length and Redundancy of Outpatient Progress Notes Across a Decade at an Academic Medical Center. JAMA Netw Open. 2021 Jul 1;4(7):e2115334. doi: 10.1001/jamanetworkopen.2021.15334. PMID: 34279650; PMCID: PMC8290305.

6. Baumann LA, Baker J, Elshaug AG. The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy. 2018 Aug;122(8):827-836. doi: 10.1016/j.healthpol.2018.05.014. Epub 2018 Jun 5. PMID: 29895467.

7. Knaup P, Garde S, Haux R. Systematic planning of patient records for cooperative care and multicenter research. Int J Med Inform. 2007 Feb-Mar;76(2-3):109-17. doi: 10.1016/j.ijmedinf.2006.08.002. Epub 2006 Sep 25. PMID: 16996787.

8. Stanhope V, Ingoglia C, Schmelter B, Marcus SC. Impact of person-centered planning and collaborative documentation on treatment adherence. Psychiatr Serv. 2013 Jan;64(1):76-9. doi: 10.1176/appi.ps.201100489. PMID: 23280459.

9. Perlich A, Meinel C, Zeis D. Evaluation of the Technology Acceptance of a Collaborative Documentation System for Addiction Therapists and Clients. Stud Health Technol Inform. 2018;247:695-699. PMID: 29678050.

10. Matthews EB. Computer use in mental health treatment: Understanding collaborative documentation and its effect on the therapeutic alliance. Psychotherapy (Chic). 2020 Jun;57(2):119-128. doi: 10.1037/pst0000254. Epub 2019 Oct 10. PMID: 31599638.

11. Warner JL, Smith J, Wright A. It's Time to Wikify Clinical Documentation: How Collaborative Authorship Can Reduce the Burden and Improve the Quality of the Electronic Health Record. Acad Med. 2019 May;94(5):645-650. doi: 10.1097/ACM.0000000000002613. PMID: 30681451.

12. Steinkamp J, Kantrowitz J, Sharma A, Bala W. Beyond Notes: Why It Is Time to Abandon an Outdated Documentation Paradigm. J Med Internet Res. 2021 Apr 20;23(4):e24179. doi: 10.2196/24179. PMID: 33877053; PMCID: PMC8097521.

13. Steinkamp J, Sharma A, Bala W, Kantrowitz JJ. A Fully Collaborative, Noteless Electronic Medical Record Designed to Minimize Information Chaos: Software Design and Feasibility Study. JMIR Form Res. 2021 Nov 9;5(11):e23789. doi: 10.2196/23789. PMID: 34751651; PMCID: PMC8663541.

Submitted by (Matthew Hudkins)