Growing Length of EHR Clinical Notes Raises Clinician Burnout Concerns

EHR clinician progress notes have grown longer and more redundant across care specialties in recent years, according to a study published in JAMA Network Open that raises concern for clinician burnout.

The cross-sectional study analyzed 2.7 million clinical progress notes written by 6,228 clinicians and staff members at an academic medical center during the decade following the 2009 passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act.

The researchers found that between 2009 and 2018, median note length increased from 401 words 642 words, a 60.1 percent increase.

Additionally, median note redundancy (the proportion of text identical to the patient’s last note), increased by 10.9 percent from 2009 to 2018, going from 47.9 percent to 58.8 percent.

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.

The researchers found that being a newer employee was associated with longer clinical notes; residents and fellows wrote 26.3 percent longer notes than more senior authors.

Each year later an author began using the EHR was associated with a 1.8 percent increase in note length.

“The causes of this cohort association are unclear,” the study authors noted. “Future work might explore whether this cohort association extends beyond note lengths to differences in note contents.”

The study also found that 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.

The study found that authors used templates more frequently than they copied and pasted text; nearly four times as much text written in 2018 was templated as was copied (55.9 percent vs 14.7 percent).

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.”

Previous studies have found that adjusting templates has helped clinicians write shorter, higher quality clinical notes, the researchers noted. These studies recommend limiting the automatic import of large data fields such as medication lists and designing text prompts to encourage independent clinician input.

“The simultaneous significant association of note length with time, cohort, trainee status, and method of text entry suggests the factors driving note bloat are multiple, interwoven, and complex,” they wrote. “Policies and practices aimed at reducing note bloat will likely need to be similarly multifaceted.”

For instance, a multifaceted approach could include addressing note template design while improving clinical documentation training.

“This study provided a baseline measure of note bloat in the decade following the passage of the landmark HITECH Act,” the study authors wrote. “It remains to be seen how recent policy changes affect clinical notes in the future.”