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EHR Clinical Note Length Continues to Grow Despite Coding Changes
While the average EHR clinical note length has increased by 8.1 percent over the past three years, the average time spent writing notes has decreased.
Despite EHR coding changes enacted in 2021 aimed at reducing documentation burden, an Epic Research report has found that the average EHR clinical note length has continued to increase.
Researchers evaluated 1.7 billion clinical notes written by 166,318 outpatient providers from May 2020 to April 2023.
They found that the average length across all clinical notes increased 8.1 percent from May 2020 to April 2023. However, even though the average note length increased, the average time spent writing notes decreased by 11.1 percent over this same period.
The researchers also compared each provider’s average note length in 2020 to that same provider’s average note length in 2023. About 40 percent of providers decreased their average note length over the three years.
The research also revealed that almost 90 percent of providers reduced the average time they spent writing each clinical note.
Additionally, 10 percent of providers who decreased their average note lengths the most came from various specialties, including primary care, internal medicine, surgical specialties, dermatology, cardiology, and psychiatry. The researchers noted that this suggests a reduction in note length is achievable in almost any specialty.
The study also found that organizations that lowered their use of SmartTools—documentation tools that make it easy to add additional content to clinical notes from other places in the EHR—reduced their average note length.
On the other hand, organizations that increased note length saw continuous use of SmartTools and increased use of copy/paste functions. The researchers said that these findings support previous research that found increased use of SmartTools and copy/paste functions were correlated with longer EHR notes.
The authors emphasized that although average note length increased, most providers spent less time writing notes, which could help clinicians deliver more patient-centered care or reduce work after hours.