EHR Documentation Styles May Impact Work Hours, Clinician Burden

First-year medicine residents who wrote clinical notes in a localized time period during the morning or afternoon spent less time at work, according to a study published in JAMIA. The study suggests the need for further research to examine how different EHR documentation styles may impact clinician burden.

Researchers examined progress note production styles for Internal Medicine residents at the University of California, San Francisco who started their first year on June 21, 2018, using unsupervised machine learning methods.

The progress notes covered 279 inpatient encounters in which patients were admitted during three two-week periods (last two weeks of June, first two weeks of July, and first two weeks of October) to capture a sample of periods in the academic year.

The study revealed several distinct user styles and potential relationships between these styles and work hours.

Some residents tended to write their notes in a more dispersed manner throughout the day. These individuals also tended to work more hours compared to residents who adopted different note writing styles.

These residents may spend more time at work due to task-switching. For example, coming back to notetaking throughout the day may mean that more time needs to be spent reviewing the patient history and the note’s contents.

In contrast, residents that tended to write their notes in a localized time period in the morning and afternoon spent less time working per day.

“By writing the note in the morning and afternoon rather than in the evening, more information that is relevant for the note may be present by that time and/or on top of the resident’s mind,” study authors wrote.

Other residents wrote notes in short sessions later in the evening. This could result in more time spent on notetaking overall because of a need to spend more time recalling information for the note after seeing the patient earlier in the day.

“Our findings, illustrating that note writing is often done in multiple sessions through the day, agree with prior work characterizing clinical documentation as a fragmented synthesis activity rather than as uninterrupted composition,” the researchers noted.

The study’s authors emphasized that their analyses demonstrate correlations but do not identify causal mechanisms. Future research should analyze the implications of different note writing approaches, such as the impact on work hours, to inform EHR documentation training, they suggested.

“These hypotheses are ripe for testing in future work and, if supported, could help to identify methods of documentation that could help to reduce overall time spent at work,” the researchers wrote.

Further research could also analyze different groups of users and different types of clinical documentation metadata to better understand EHR documentation practices and the potential role of modifiable individual user preferences.

These findings could help guide EHR documentation training and inform solutions to improve EHR efficiency and address mounting clinician burden concerns.

EHR clinical progress notes have grown 60 percent longer and 11 percent more redundant over the past decade, according to a recent study published in JAMA Network Open.

Long or repetitive notes can cloud important patient information, which can lead to clinical and diagnostic errors, the study authors explained.

“Bloated notes can also have impacts beyond direct patient care, such as taking longer to write or being a poor source of data for quality improvement and research,” the study authors explained.

EHR clinician notes with higher proportions of templated or copied text were significantly longer and more redundant.

Across all specialties, less than half of note text was directly typed in 2018. In 36 specialties, less than one-third of note text was directly typed.

While templates aim to improve data standardization and prevent clinician burnout, the study revealed that templates may be hindering the value of patient health records.

“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 study authors explained. “More attention should be paid to how clinicians use note templates, how they are governed, and their impact on patient care.”