EHR Clinic Notes Need to Be Redesigned

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University of Missouri researchers are calling for the redesign of electronic health record documentation tools to better meet the needs of primary care physicians, specifically the clinic notes sections that recap a patient’s medical history.

“While EHRs have granted physicians access to more information than ever before, they also include lots of extraneous information that does not contribute to the care of the patient,” said Richelle Koopman, M.D., associate professor of family and community medicine at the MU School of Medicine and lead author of a study published in the Journal of the American Board of Family Medicine.

In the study, researchers observed primary care physicians using EHRs in preparation for patient visits and asked them to identify which parts of the clinic note they found most and least important. According to the results, doctors overwhelmingly found the “assessment” and “plan” sections of the clinic notes to be the most important, while the “review of systems” section—which is required by Medicare and Medicaid for billing purposes—was deemed the least valuable.

“Most physicians we observed skipped right to the assessment and plan sections, which include the diagnoses of the patient from the last visit and notes on how physicians planned to address the diagnoses,” Koopman said. “In addition, physicians expressed a lot of frustration about the poor utility of the ‘review of systems' section and said it had little value in addressing patient care.”

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Part of the problem, according to Koopman, is that EHR documentation “mimicked” the paper records which were difficult to navigate due to increasing federal and regulatory demands on required information, and this led to redundant, cluttered information being presented electronically.

“Current ambulatory progress notes present more information to the physician than necessary and in an antiquated format,” concludes the study. “It is time to reengineer the clinic progress note to match the workflow and information needs of its primary consumer.”  

Koopman and her colleagues recommend patient information become more organized to allow physicians to spend more time with patients instead of wading through notes to find the most valuable information. In addition, they say research supports changes to the information needed for medical billing with a more streamlined way of presenting medical information that can ultimately reduce medical errors.

Future research will include identifying ways to organize patient information in clinical notes by using eye-tracking software to see how quickly physicians can find information using different clinical note prototypes created by researchers.

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