EHR Flowsheet, Documentation Challenges Cause Clinician Burnout

Optimizing and simplifying the EHR flowsheet to structured response fields rather than a text input dialogue could help reduce clinician burnout and aid EHR documentation, according to a study published in JMIR Publications.

Clinical EHR documentation was initially designed to record clinical information as provider notes in real-time during a consultation, assessment, imaging, or treatment, ultimately to share patient information among health providers.

While the transition from paper to EHR documentation has allowed for more accessible and legible notes, it is a primary cause of clinician burden. EHR documentation can cause information overload and yield larger amounts of text that is not always relevant to patient care.

Although health IT specialists are working on EHR solutions, like voice recorders, to reduce documentation-related burden. These are in early prototype phase and are unlikely to be integrated into practices in the near future, the study authors wrote. As a result, optimizing existing EHR system functionalities could be a more practical option.

The research team aimed to evaluate the free-text comments that clinicians can enter into EHR flowsheets to boost EHR documentation and mitigate clinician burnout.

Flowsheets are EHR-integrated tools developed to help clinicians document patient data in a grid-like format. The clinician enters values into a cell from certain lists in each flowsheet entry. Clinicians can enter supplementary comments but they are voluntary.

“Although the flowsheet comments are optional, some health care providers find them useful and make an extra effort to provide them,” the study authors explained. “However, comments may introduce a documentation burden stemming from limitations in the existing EHR functionality. Given that flowsheet comments are made accessible in a nonobvious manner, we believe that their content can be leveraged to design more effective strategies for efficiently recording them.”

The study authors assessed nearly 210,000 vital sign flowsheet comments at Vanderbilt University Medical Center and added natural language processing and topic modeling to extract generally discussed topics and medical terms.

The study showed 63 percent of clinicians who documented vital signs entered at least one free-text comment in the flowsheet. Specifically, registered nurses, technicians, and licensed nurses were the most likely to enter the comments. Measurement context, vital sign issues, and provider notifications to other providers most commonly cropped up in free text.

The researchers found over 4000 unique medical terms, with many being symptom-related or drug-related.

“These nurses and technicians clearly felt the need to capture more information than the simple numeric value that the flowsheet required, as documented in a study that examined the flowsheet comments for 201 patients who experienced cardiac arrest,” wrote the study authors. “However, despite its potential usefulness, our findings suggest that there are better alternative solutions for effective information recording.”

The research team offered two recommendations to improve the functionality and ultimately reduce clinician burden.

The ability to enter free-text comments in a flowsheet row could be removed from the EHR system.

“Although this may save health care providers’ time and effort, it should only be considered after a careful examination of the utility of this functionality, an endeavor that is beyond the scope of this investigation,” the study authors explained.

Additionally, the health system could optimize it to create structured response fields instead of a text input dialogue. This would let the organization store patient information that some nurse respondents said might be being used to protect the user from future lawsuits.

“This design should be suitable for capturing when a measurement is reliable or unable to obtain as well,” the study authors wrote. “Moreover, any medical-related information should be recorded in clinical notes for future reference. We believe that such a design will be much more efficient and ensure that important information can be easily reviewed in the future. However, we acknowledge that a user-centered design approach would help understand the need for, as well as how to improve, the functionality.”