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Effective healthcare documentation is crucial to convey clinical information about a patient’s diagnosis, treatment, and outcomes, for communication between clinicians and payers, and to avoid compliance issues. Outsourcing medical transcription is a widely accepted strategy to ensure complete and accurate electronic health record (EHR) documentation and ease physician burnout. In fact, several studies have reported that physician stress and burnout are directly linked to EHRs. According to a recent study, EHR progress notes are becoming lengthier and more redundant in all specialties, increasing clinician burnout concerns.
Templates Undermining the Value of the EHR
The research, which was published in JAMA Network Open, was based on a study of 2.7 million clinical progress notes created by 6,228 clinicians and staff members at an academic medical center between 2009 and 2018. The researchers found that in the decade since EHRs were adopted in 2009, median note length increased 60.1 percent, from 401 words to 642 words. Other findings of the study:
- Median note redundancy (the proportion of text identical to the patient’s last note), increased from 7.9 percent to 58.8 percent, by 10.9 percent.
- Newer employees (residents and fellows) wrote 26.3 percent longer notes than more senior employees.
- Each year after an author started using the EHR saw a 1.8 percent increase in note length.
- EHR clinician notes that had a higher proportion of templated or copied text were significantly longer and more redundant.
- In all specialties, less than 50% of note text was directly typed in 2018. In 36 specialties, less than one-third of note text was directly typed in.
- Up to 55.9 percent text written in 2018 was templated as compared to 14.7 percent which was copied.
Templates may be taking away from the value of patient health records, according to the study. The researchers wrote: “Templates can reduce documentation time and increase standardization, but can also add potentially irrelevant information or introduce errors, as when used to insert default examination findings which were not actually observed.”
The researchers concluded that patient care notes have become lengthier and more redundant since electronic health records were adopted in 2009. The two key findings of the study are:
- A major proportion of note text is templated or copied
- Residents, fellows, and more recent hires write significantly longer notes
Another study published in 2018 analyzed similarity in progress notes from successive outpatient ophthalmology encounters. This study also found that content importing technology results in duplication of large amounts of clinical text in EHR progress notes. The key points highlighted by the researchers are as follows:
- The average ophthalmology progress note is long.
- The major portion of each note subsection is identical to prior notes.
- Important note sections make up a small portion of overall length.
- EHR content importing technology has made it more difficult for physicians to find the most important sections of the note.
- Copied text may be outdated or internally inconsistent and the errors may propagate throughout subsequent notes.
- Redundant information makes it difficult to distinguish between current and historical data, and when and by whom the documentation was first written.
- Reading longer progress notes takes more time.
The researchers noted that importing large amounts of EHR data may reduce the reliability of the medical record.
Institutional Policies and EHR Redesign can make a Difference
Institutional policies can make a difference by encouraging brief, succinct progress notes and restricting the use of templates that import medication lists or past medical history. Such information is associated with a patient encounter but should be kept separate from the main body of the progress note text.
EHRs should be redesigned to limit the amount of computer-generated text inserted into the progress note. Billing and other information that is not directly related to patient care should be kept separate from clinician-generated text or displayed only on demand instead of by default. EHRs should also provide physicians with more control over how and where important information is displayed.
How Medical Transcription Outsourcing Helps
Partnering with a medical transcription company to aid with documentation can decrease clinician burden. Experienced medical transcriptionists can ensure accurate and timely EHR documentation. With a reliable company handling their EHR documentation tasks, physicians can focus on strengthening relationships patients and optimizing care.