Best practices, template improve EHR documentation quality

While the use of electronic health records by providers is nearly universal, it has resulted in major challenges in managing EHR documentation by doctors, who are more likely to include inaccurate, inconsistent and excessive information in progress notes on patients.

The phenomenon is known as “note bloat,” a moniker for the trend describing how physician notes contain multiple pages of nonessential information, according to Neveen El-Farra, MD, associate clinical professor of medicine and associate dean for curricular affairs at UCLA’s David Geffen School of Medicine.

“The electronic health record makes it so easy to import all this data,” adds El-Farra, who is also a hospitalist in the Department of Medicine and associate program director of the internal medicine residency program. “EHRs were supposed to be the best things ever, but they have a lot of issues and are the No. 1 cause of burnout among physicians.”

However, internal medicine residency programs at four academic institutions found that by prompting doctors to document in the EHR only what is relevant for that day and by limiting shortcuts—such as copy-and-paste and autofill—notes were significantly improved in terms of quality and shorter overall. In addition, such practices reduced the length of time required for doctors to complete documentation.

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Intern physicians on inpatient internal medicine rotations at UCLA, the University of California San Francisco, the University of California San Diego and the University of Iowa participated in a non-randomized prospective trial that used a set of best practice guidelines and a template for progress notes. Note quality was rated based on a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9) and a competency questionnaire.

“Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete,” state the authors of the study, which was published last week in the Journal of Hospital Medicine.

In addition, the notes in the study “had approximately 25 percent fewer lines and were signed on average 1.3 hours earlier in the day,” according to the authors.

El-Farra and her co-authors observe that physicians typically spend a considerable amount of time writing notes in the EHR, so it was “encouraging to find that post-intervention notes were signed 1.3 hours earlier in the day.” She contends that this time savings could translate into more time spent on direct patient care.

Still, data from the study revealed variation between the four academic institutions—all of which use an Epic EHR—when it came to template use: 92 percent at UCSF, 90 percent at UCLA, 79 percent at Iowa, and only 21 percent at UCSD. Nonetheless, while UCSD reported low template use among its interns, they still showed evidence of improvement in note quality in the study.

Because UCSF and UCLA created the best practice guidelines and template for the study, the authors suggest that the intervention might have been a “better fit” for the cultures of their respective organizations and that perhaps they had more institutional buy-in from the outset.

“We still have a long ways to go,” acknowledges El-Farra. “Some of our residents continue to use the note template; others don’t. We probably need to do a refresh, and it probably needs to be built into some sort of orientation for new interns so as they become residents they won’t—hopefully—fall into the habits of the copy-and-paste, note bloat and just importing data that has no synthesis and lacks any thought process.”