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Medical record keeping has evolved over the years. Formerly, physicians dictated their notes and got the spoken reports converted into hand-written or typed notes by a medical transcription service company. With the advent of EHRs, the role of medical transcriptionists changed and they now review and edit the draft EHR reports prepared by physicians, correct mistakes, add clarifications, and improve accuracy. Today, EHR note bloat and cloned notes are a major problem for all physicians, regardless of their medical specialty.
Documenting interactions with patients is essential for healthcare to work. There are many reasons why clinicians maintain clinical documentation:
- To help recall what was happening with the patient and what was said and done
- To communicate to other clinicians
- To defend against allegations of malpractice
- To prove that quality care was provided
- To engage patients in their care
- To get paid for services rendered
The problem is that the perceived requirement to meet regulatory needs with proper and comprehensive documentation has led to lengthy, unclear notes that serve no purpose.
Reasons for EHR Note Bloat
Medical records document the patient’s history. This allows physicians to review past data, and allows information to be shared in an organized way with other providers involved in the patient’s care. Recording patient history and dictating notes requires physicians to be succinct, detailed, and empathetic. In the days of hand-written notes, physicians or their medical transcription company completed preparing the notes after the patient visit.
Note bloat in an EHR system occurs when physician clinical notes contain too much unnecessary information, in most cases, missing or concealing critical or time-sensitive information in the patient’s record.
Today, EHRs require physicians to record a lot of information during the office visit, even as they are performing a physical and speaking to the patient. A Forbes article noted: “As the information is entered into the medical record, the system prompts the doctor on additional questions to ask, physical exams to perform, tests to order, and treatments to consider”. It’s hardly surprising that in place of cohesive and concise notes, EHRs have resulted in the phenomenon called note bloat. The key reasons for note bloat are as follows:
- EHR documentation tools: EHR systems offer clinicians various time-saving tools for documentation such as dictation, templated pull-down menus, direct keyboard entry, interfaces with supporting systems, and automatic text generation or copy-paste. All of these result in unnecessary documentation and confusion. Copy and paste saves time, but can cause redundancy and other risks.
- Documentation to warrant the patient’s bill to their insurance company: While documenting more information does not contribute anything to patient care, providers who are not knowledgeable about coding requirements, may end up including more clinical data to support higher value billing codes. To decrease documentation burden and note bloat and make code selection more intuitive, CMS has overhauled the rules for office-based Evaluation and Management services.
- Meet productivity goals: Paperwork and administrative requirements have increased significantly, leading physicians to include more documentation than necessary using auto population and copy-paste. For example, as a Medscape article points out with diagnosis-related group (DRG) classifications, physicians have to maintain a high case-mix index. Sam Butler, MD, who was Epic’s chief medical officer (CMO), explains that physicians have to prove they have sick patients if they want to get paid.
- Fear of litigation: Fear of missing something that could result in litigation is another reason why providers generate long clinical notes. In the event of a lawsuit, all the information can be presented in one place “to demonstrate all Ts were crossed and all Is were dotted”. However, the truth is that, when previously recorded unnecessary and unreviewed peer notes pile up, they will mask the medical findings and the physician can lose the case.
How to Avoid Note Bloat
Note bloat prevents efficient, compliant clinical documentation and can promote higher quality care. Here are some top strategies that experts recommend to avoid note bloat:
- Focus on communicating information that is important at that moment: According to a For the Record article, clinical notes should inform the care team what the clinical situation is, provide recommendations and perceptions on a care plan, and why that care plan is the best course of action at that moment. While the patient’s history and previous treatment plans should be considered, the note should focus on what’s happening on that day and what needs to be done next. If a condition has been resolved, this should be mentioned in the note.
- Training: EHR documentation training can improve documentation accuracy and also save time, reducing the number of hours physicians spend on entering information into the system. With EHR training for clinicians, practices can not only increased documentation and coding accuracy, but also realize the EHR’s full potential, improve efficiency and productivity, and boost user satisfaction.
- Improve template design: Research shows that redesigning the EHR template can improve documentation and reduce note bloat. A study published in the Journal of Hospital Medicine found that a newly designed best practice progress note template for writing daily progress notes considerably improved the quality of EHR notes, decreased their length, and helped clinicians complete notes faster.
- Use technology: Computer-assisted physician documentation solutions that employ artificial intelligence and NLP can help physicians and the CDI team to produce effective notes. These technologies can evaluate clinical notes and create data summaries that can the provider identify the relevant items contained within the patient’s chart, and even find out if anything has been miscoded or undercoded.
EHR notes play a key role in helping physicians take important decisions on care plans, codes, and billing, and much more. However, when primary care physicians have to constantly look the computer screen to take notes, it can take away time from interacting with the patient. Family practice medical transcription services are an ideal solution to this problem. With expert support, physicians can focus on the patient, while adhering to documentation principles.