Writing Notes to Patients – Not about Them

By:
Ethan Cumbler, MD, FHM, FACP
Sarguni Singh, MD
University of Colorado School of Medicine

What’s the purpose of attending documentation on a resident’s progress note? The answer might seem obvious, but stop and think about it. Often, the attestation is a detailed exposition of the attending’s own thought process on the diagnosis, differential, and work-up being completed to resolve the patient’s acute medical issue. Written in the arcane language of the profession of medicine, this is a daily note from doctors… to doctors.

Yet time spent in front of a computer documenting in the EMR makes many of us on the front lines of medicine feel that we are losing time we would rather spend communicating directly with our patients. We could shorten the attestation to the minimum to fulfill regulatory and billing requirements, but then our own thoughts and plans for the day would be lost. Neither the short nor long attending attestations really helps us communicate with our patients. What would happen if we were to fundamentally redesign our hospital documentation with the central goal of improving communication with patients?

On the Acute Care for the Elder service at the University of Colorado Hospital, we began to wonder if there was a way for attendings to spend a portion of their documentation time in a way that improved and promoted communication with patients and their families. What if we “re-purposed” some of our attending documentation on the teaching wards to focus on actual communication with patients? We started to experiment with writing letters to patients during their hospitalization. Take a look at this sample.

In this new model, instead of writing the typical doctor’s note in the chart, we asked attendings to write a letter directly to the patient, in plain language, explaining the reason for their hospitalization, the plan of care for the day, and when they think the patient might be able to go home. These letters are typically a couple of paragraphs in length and labeled “treatment plan” in our EMR. They become part of the record of the patient’s care in the hospital, but we also print them out and give them to patients, typically on the second day of hospitalization.

This complements, rather than completely replaces, other forms of attending documentation. There is still, of course, a daily one-line attestation to the resident note fulfilling billing and regulatory requirements. The first day of the hospitalization also remains a traditional “physician’s note.”

We think on the first day of hospitalization, the core challenge is considering the diagnosis, differential, and management plan. Traditional documentation offers value in how it facilitates this thought process. However, after this first encounter, physicians’ time might be better spent translating these thoughts into language the patient can understand. Our time spent documenting in the EMR could then serve a dual purpose.

As an attending, this approach offers a chance to demonstrate to residents something that is rarely modeled in the EMR – patient communication. We  asked our attendings to try this concept out. Our early experience was met with encouraging feedback. We heard that the letters engage some patients further in their care. Nursing staff reported receiving positive responses from patients and feel that these letters help them in their own communication with patients and family members about care plans. We were hearing that residents read these notes in the chart and field questions from patients about them. Some patients made a point to tell us that this personal, written form of communication is considerate and helpful in understanding the care they are receiving in the hospital. One patient told us she photographed her letter on her smart phone and sent the image to multiple children who live in different states to keep them in the loop on how her hospital stay was going so far.

We decided to survey our physicians about their experience with the letters to patients during hospitalization.  They told us that they would define success as improving patient and family satisfaction, understanding of the care plan, and helping patients feel more empowered. They also told us that not increasing clinician documentation burden and making it easy to get the letters to patients was important to them for sustainability. We heard from the folks writing these letters that it improved their own satisfaction with the communication they were providing to patients.

Of course, success in a communication project has to be examined from the patient’s perspective. We have students on our unit right now interviewing patients and family members to better understand how patients perceive these letters, what kind of information patients find helpful during a hospital stay, and how we can get better at writing them. We will watch our patient satisfaction ratings and learner evaluations to better understand the impact these letters have on patient care in a learning environment. The key question is whether this could spread further to other units in the hospital, across our health system, or beyond.

We can speak to our own experience with these letters.  For the first time, attending documentation feels uniquely value-added and purposeful in its intent to improve communication between the teaching team and patients.

This simple re-frame – writing a letter to patients instead of a note about them – has offered a chance to strive for the principle of patient-centricity. One of the joys of being a doctor in hospital medicine is that we have a chance to redesign the healthcare system – sometimes in big ways, and other times, in small and personal tests of change.

Interested in giving this a try in your hospital? We would be happy to share what we have learned so far. Comment below or contact:

Ethan Cumbler,
Medical Director University of Colorado Hospital ACE Unit
Professor of Medicine
University of Colorado School of Medicine

Sarguni Singh, MD
Assistant Director ACE Services
Assistant Professor of Medicine
University of Colorado School of Medicine