Reducing EHR-driven documentation burdens via the Ideal Note

Eliminating the documentation challenges that contribute to clinician burnout requires coordinated effort from across the healthcare continuum.

This article is part of the February 2023 COVERstory.

For all the benefits realized from advances in health information technology, electronic health record-driven documentation continues to exacerbate clinician burnout, which costs the healthcare system approximately $4.6 billion per year

In a recent survey by the Harris Poll for athenahealth, excessive documentation requirements were cited as the leading cause of burnout by 57 percent of clinician respondents, with nearly 60 percent saying they often feel so overloaded with information that it increases their stress. 

How to mitigate the burden of creating clinical notes — and interpreting notes from others — was the focus of the 2022 EHRA and HIMSS Physician Committee Summit: Meaningful and Streamlined Documentation. Attendees – physicians, nurses and other clinicians, as well as behavioral health specialists, informatics experts and health IT professionals – explored ways to create, receive and share meaningful notes while reducing documentation burden. 

There was early consensus on several key points. The group agreed that while the ability to create an ideal clinical note is important to the delivery of healthcare, the ability of other providers and systems — as well as the clinician’s future self — to use those notes to understand the patient’s history and inform future care decisions is equally essential. 

Attendees also concurred that the content of a clinical note should clearly and concisely capture the information needed to support medical decision-making within the context of the referenced encounter, without repetitive information from previous encounters. Content should also be patient-centered, prioritizing the information needs of the care team over billing, coding and other non-clinical needs. 

Overarching themes 

Discussions revealed several overarching themes around the ideal clinical note, and the barriers to that ideal created by both EHR systems and the various stakeholders of the note — regulators, payers and other constituents. These included making a clear distinction between documentation (the unstructured narrative of the patient’s condition and the care delivered) and charting (more structured information intended to support billing, patient monitoring and other purposes). 

While participants agreed that both aspects of the clinical note were important, the conflation of the two — in the form of clunky EHR interfaces or the need to “hack” structure within the EHR using tools intended for narrative — created problems for both clinicians and health IT and informatics specialists. 

A second theme was the overuse of “copy forward” accelerators and their contribution to note bloat. The ability to copy forward previous notes can greatly accelerate documentation. However, when the same notes are carried forward visit after visit, it results in a cascade of bloated notes for other providers and systems to contend with as they try to make sense of the story reflected in the narrative.  

Exacerbating this is the inability of most EHRs to easily track activity and interventions around the same problem over time. This leads some specialists to copy their previous notes forward and continually build on the patient narrative within individual visit notes, increasing the length of the note to unsustainable degrees. 

A final theme was over-rotating on comprehensiveness instead of documentation by exception. This refers to the tendency of some clinicians to include everything possible in a note, rather than focusing on aspects of the patient’s condition that were abnormal or had changed. While concern over perceived regulatory and billing needs can exacerbate this, the use of point-and-click templates available in most EHRs also comes into play, because they can make clinicians feel that they have to “answer every question,” regardless of its relevance to the current encounter. 

In addition to overarching themes surrounding the causes behind documentation burden and challenges to achieving the ideal note, what emerged from summit discussions was an agreement that resolving these issues required partnership among multiple players — including EHR developers, clinicians and health systems. This led to the identification of opportunities that could lay the foundation for the creation, receipt and sharing of meaningful clinical notes. 

EHR developer opportunities 

Many of the opportunities identified for EHR developers centered around gathering user feedback and leveraging it to inform system design. 

For example, technology can provide multiple ways to view and export clinical notes by default. For events such as surgery that include both documentation and charting, there can be both an export of the narrative notes and a combined surgical chart that includes the full record, including the structured documentation captured during the surgery. Clinicians need the narrative notes to inform post-op discussion and care, and the combined surgical chart is an important component of the patient’s overall chart, as well as being required for auditing and regulatory purposes. 

Additionally, technology can prioritize narrative elements when exporting or summarizing care records. A common complaint about notes received from other providers or carried over from interfaces is the need to sift through structured information, such as the patient’s allergy and problem list or demographics, to get to the information the provider needs to make the immediate care decision, most often the chief complaint, assessment/plan, and history of present illness. It would be beneficial to prioritize these sections when formatting care summaries or interface messages and include additional structured chart data at the bottom of the document for ease of reconciliation with other systems. 

Finally, records should make it easier to see the history of a specific problem. For many clinicians, particularly specialists, their focus is on a specific subset of the patient’s problem list, and they need to see what has been tried previously to inform their next step in the patient’s care. When they are unable to do this, they resort to workarounds such as copying forward previous notes to create a history within the current encounter or they complain bitterly about the EHR to their administrators. Also, developers should consider ways of displaying the timeline of interventions and clinical notes, centered around a specific problem in the patient’s problem list, to mitigate this issue. 

Clinician and health system opportunities 

For clinicians and health systems, a primary opportunity comes from considering who the audience is for the clinical note, and how and why it will be accessed after it's created. For example, the note may be: 

  • • Sent to the patient or their caregiver(s) as a care summary
  • • Imported via interface message (HL7 or CCDA) to another EHR
  • • Exported as part of a medical record request
  • • Listed or summarized elsewhere in the patient's chart in a timeline or document view
  • • Reviewed by another clinician responsible for providing care to the patient
  • • Reviewed by billers, coders, and authorization professionals to ensure appropriate payment

While the EHR can handle many aspects of formatting the information within notes for these different audiences, clinicians have a responsibility to ensure their narrative clearly and concisely communicates the primary information which supports clinical decision-making. Additionally, with the increasing call for interoperability and patient access to their clinical data, the language used should be accessible to various readers, including those with limited clinical knowledge.  

As such, providers should avoid using “copy forward” accelerators to continue building upon the patient’s story and focus instead on capturing just the information that is relevant to that visit, which is where the true value of the note resides. Doing so will benefit not only those clinicians who review the note later, but also billers and coders who often complain about clinicians’ notes not having the right information to support the expected E/M level. 

Encouraging documentation by exception is another opportunity. Structured templates and questionnaires can be significant accelerators to documenting care and can provide a visual reminder of things to look out for when examining a patient for a given condition or visit type. However, when clinicians feel compelled to enter something on every single item in a structured template regardless of its clinical significance, it creates a sea of irrelevant information that they and others will need to sift through to find the most important content. Instead, clinicians should be encouraged to report only the most clinically significant findings for a patient when using these tools. 

An evolved purpose 

The purpose of an Ideal Note has evolved beyond that of revenue generation. The current healthcare environment demands digital communication handoff throughout the continuum of care, which aligns with the Institute of Medicine’s framework for quality as defined by the safety, effectiveness, efficiency, equity and patient-centeredness domains.  

Achieving this ultimate purpose – and eliminating the documentation burdens that contribute to clinician burnout – requires coordinated effort from across the healthcare continuum. 

Dani Nordin (athenahealth) is chair and Tammy Coutts (MEDITECH) is vice-chair of the EHR Association’s user experience workgroup.

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