Free Healthcare IT Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Get all the latest Health IT updates from Neil Versel for FREE!

APSO vs. SOAP, continued

A couple weeks ago, I had a story in Healthcare IT News about the growing use of the “APSO” notes for documenting patient encounters. APSO flips around the traditional SOAP format (subjective, objective, assessment, plan), ostensibly making it easier to view progress notes in electronic health records.

As I reported, APSO is in wide use at University of Colorado Health and at Lucile Packard Children’s Hospital in Palo Alto, Calif. Baystate Health in Springfield, Mass., found that hospitalists focused most of their attention on the “impression and plan” sections of patient records, essentially the AP part of APSO/SOAP. Physicians at Epic Systems, according to University of Colorado’s Dr. C.T. Lin, are recommending APSO as a best practice.

Yet, the inventor of the SOAP note, Dr. Larry Weed, still believes his format is superior. You saw his comments in the Healthcare IT News story. But every time I have the privilege of speaking to the nonogenarian Renaissance man, he always has more to say than I can fit into the average article. I often can’t keep up in my note taking, but, fortunately, in this case, Weed and his son/occasional co-author Lincoln, took the time to put their thoughts in writing for me.

I left most of their comments out of the story due to space limitations. I don’t have that problem here, so I present their entire statement to me:

The following represents our collective thoughts, including references to relevant portions of Medicine in Denial [their 2012 book].

The supposed advantage of the APSO alternative — that it begins with the physician’s assessment rather than data — is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based.  In contrast, beginning the progress note with data disciplines the provider’s assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it’s important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called “objective” data,  As Medicine in Denial states (p. 168):
“… progress notes should begin with subjective data, because progress should be assessed from the patient’s point of view.  Practitioners should be alert to discrepancies between subjective and objective data (for example, where the patient does not feel better when lab results show improvement). These discrepancies may signal an error in data or misstatement of the patient’s problem.”
In short, provider thinking can be disciplined with problem-oriented SOAP notes as a standard of care. Yet, regulators and academics who are in a position to act on this issue have shied away from the whole notion of standards of care for organizing data in medical records. See our comments on ONC’s Stage 2 regs and our comments on the PCAST Report.
The need for standards of care in medical records goes far beyond the SOAP vs. APSO issue in progress notes. In fact, that issue is secondary. Two more fundamental issues for medical records are the following:
  1.  Determining initial inputs to the record. Initial inputs are determined by selection of data needed for the patient’s problem situation, and once the data are collected, analysis of the results.  Both selection and analysis are fatally compromised when determined by the physician’s clinical judgment. External standards and tools, based on a combinatorial standard of care, must govern the selection and analysis. Once that happens, then judgments of patient and practitioners (not just physicians) may supplement the combinatorial minimum standard.  See Medicine in Denial, pp. 53-61, 69-79, 136-37, 145-52.
  2.  Organizing the medical record around the problem list. Once initial data are collected and a complete problem list is defined, then care plans, orders, and progress notes should be problem-oriented, that is, labeled by the problem(s) to which they relate on the problem list. This disciplined practice is essential to justifying provider actions in terms of defined patient needs. Yet this practice is not followed or enforced with consistency. Indeed, some EHR systems do not even enable electronic links between the problem list and care plans, orders and progress notes. See Medicine in Denial, pp. 134-35, 144, 159-60, 166-67.
Like so much else in medicine, medical record practices are a Tower of Babel. Medicine need standards of care for managing clinical information (knowledge and data) no less than the domain of commerce needs accounting standards for managing financial information. This failing is a primary root cause of the health care system’s failures of quality and economy.

For that matter, Lin had more to say than what you saw in the story. He discussed the supposed importance of the subjective and objective elements. “That’s true in cases where there is diagnostic uncertainty,” Lin said. But he added that those components are still there for reference, jut not up front.

Lin called SOAP “a phenomenal innovation,” but suggested that EHR complexity sometimes makes it difficult to find the assessment and plan. For example, he said that a non-Epic EHR in the emergency department at UC Health has as many as 17 different screens for progress notes. “At least with APSO, you would collect the assessment or plan in the first half,” Lin said.

Because SOAP is so entrenched, Lin ran into much resistance when he proposed switching to APSO at 40 affiliated practices. He, of course, heard the tired, “But we’ve always done it this way” defense.

“I learned myself about culture change very acutely,” Lin said. “I was literally shouted out of the room by our physician leadership.” He had neglected to prepare the heads of various departments and clinics for the change in advance of the meeting where he announced the plan.

He subsequently had to have individual conversations with all 40 practice directors. And then Lin dropped a great quote from none other than Niccolo Machiavelli (speaking of Renaissance men): “Those who benefited from the old order will resist change very fiercely.”

Yes, that’s absolutely perfect for an industry as resistant to change as healthcare. But is APSO superior to SOAP? I’d love to hear your thoughts.

May 20, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Patient safety update

I’m passionate about patient safety. I’m happy to report a couple of things that aren’t exactly breaking news, but still worth bringing to your attention.

First off, there is a fairly new peer-reviewed journal called Diagnosis, and it’s about exactly what the title suggests. The first, quarterly issue, from German academic publisher De Gruyter (North American headquarters are in Boston), came out in January, so the second issue should be published soon. The online version is open access. That means it’s free. (A print subscription is $645 a year.)

A highlight of the premiere issue is a submission from the legendary Dr. Larry Weed and his son, Lincoln Weed, discussing diagnostic failure and how to prevent it. “Diagnostic failure is not a mystery. Its root cause is misplaced dependence on the clinical judgments of expert physicians,” they begin. The answer? Clearly defined standards of care and wider use of clinical decision support tools. It’s not anything new. Larry Weed has been advocating this for a good 50 years and saying that the unaided human mind is fallible for probably 60 years. Yet, medicine still largely relies on physicians’ memory, experience and recall ability at the point of care.

This doesn’t mean evidence-based medicine ,which is based on probabilities. Probabilities are fine when the patient has a common condition. They’re useless for outliers. No, Weed has long said that IT systems should help with diagnosis by “coupling” knowledge to the patient’s particular problem, and this starts with taking a complete history.

Weed, of course, created the SOAP (subjective, objective, assessment, plan). I recently talked to a CMIO who is advocating flipping that around a bit  into an “APSO” (assessment, plan, subjective, objective), which he said works better with electronic records. I’ll have more on that in an upcoming article for a paying client, and I’ll probably want to dive into that again in the near future.

For those who still believe American healthcare is safe, effective and efficient, ProPublica worked with PBS Frontline and marketing firm Ocupop last year to produce a video “slideshow” called “Hazardous Hospitals.” It’s worth a view for healthcare industry insiders, and definitely merits sharing with laypeople. I recommend that you share it. Please. Do it. Now. I’m serious. Patient safety is a problem that doesn’t get enough attention. :)

 

March 25, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.