How Does One Herd a Few Hundred Thousand Sheep?

 This post was originally featured on HIStalk.

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.