Relationship between documentation method and quality of chronic disease visit notes

Comparison of medical documentation between pharmacist-led anticoagulation clinics and physician-led anticoagulation clinics: A retrospective study

Background and objectives

High-quality documentation is critical in medical settings for providing safe patient care. This study was done with the objective of assessing the standard of medical records in anticoagulation clinics and investigating the distinctions between notes written by pharmacists and physicians.

Methods

A retrospective cross-sectional analysis of data from electronic health records (EHRs) was performed on patients who received anticoagulation and were observed at anticoagulation clinics from October to December 2020. Patients were monitored in two anticoagulation clinics, one administered by pharmacists and the other by physicians. The quality of the documentation was assessed using a score, and the note was assigned one of five categories according to its score: very good, good, average, poor, and very poor. The data was analyzed using Stata/SE 13.1. P value<0.05 was considered significant in all analytical tests.

Results

A total of 331 patients were included. While 160 patients (48.3%) were followed by the physician-led clinic, 171 (51.6%) were by the pharmacist-led clinic. The average age of the patients was 54 ± 15. 60.73% of them were female, and 90.3% of them were Saudi nationals. Warfarin was the most widely used anticoagulant (70%), followed by rivaroxaban (15.7%). Compared to physicians, pharmacists demonstrated very strong documentation (54% vs. 18%). The examination of the variables considered in the study revealed that physicians had significantly less drug-drug interaction documentation (17 vs. 71 times) or drug-food interaction documentation (23 vs. 71 times) than pharmacists. In terms of follow-up frequency, pharmacists were found to adhere to the clinic protocol (150 times) more frequently than physicians (104 times). However, there was no significant difference in therapeutic plan documentation between the two groups. (p = 0.416).

Conclusion

Pharmacists were more comprehensive in their documentation than physicians in anticoagulation clinics. Unified clinic documentation can ensure consistent documentation within EHRs across all disciplines.

The Use of Templates for Documenting Advance Care Planning Conversations: A Descriptive Analysis

CONTEXT

While professional societies and expert panels have recommended quality indicators related to advance care planning (ACP) documentation, including using structured documentation templates, it is unclear how clinicians document these conversations.

OBJECTIVE

To explore how clinicians document ACP, specifically, which components of these conversations are documented.

METHODS

A codebook was developed based on existing frameworks for ACP conversations and documentation. ACP documentation from a hospital medicine quality improvement project conducted from November 2019 to April 2021 were included and assessed. Documentation was examined for the presence or absence of each component within the coding schema. Clinician documented ACP using three different note types: template (only template prompts were used), template plus (authors added additional text to the template), and free text only. ACP note components were analyzed by note type and author department.

RESULTS

A total of 182 ACP notes were identified and reviewed. The most common note type was template plus (58%), followed by free text (28%) and template (14%). The most frequent components across all note types were: important relationships to patient (92%), and discussion of life-sustaining treatment preferences (87%). There was considerable heterogeneity in the components across note types. The presence of components focused on treatment decisions and legal paperwork differed significantly between note types (P < 0.05). Components on preference for medical information, emotional state, or spiritual support were rarely included across all note types.

CONCLUSION

This study provides a preliminary exploration of ACP documentation and found that templates may influence what information is documented after an ACP conversation.

Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study

BACKGROUND

The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation.

OBJECTIVE

To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types.

DESIGN

Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours.

PARTICIPANTS

A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021.

MAIN MEASURES

Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit.

KEY RESULTS

Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit).

CONCLUSIONS

Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.

Merit-based incentive payment system participation and after-hours documentation among US office-based physicians: Findings from the 2021 National Electronic Health Records Survey

BACKGROUND

After-hours documentation burden among US clinicians is often uncompensated work and has been associated with burnout, leading health systems to identify root causes and seek interventions to reduce this. A few studies have suggested quality programme participation (e.g., Merit-Based Incentive Payment System [MIPS]) was associated with a higher administrative burden. However, the association between MIPS participation and after-hours documentation has not been fully explored. Thus, this study aims to assess whether participation in the MIPS programme was independently associated with after-hours documentation burden.

METHODS

We used 2021 data from the National Electronic Health Records Survey. We used a multivariable ordinal logistic regression model to assess whether MIPS participation was associated with the amount of after-hours documentation burden when controlling for other factors. We controlled for physician age, specialty, sex, number of practice locations, number of physicians, practice ownership, whether team support (e.g., scribes) is used for documentation tasks, and whether the practice accepts Medicaid patients.

RESULTS

We included 1801 office-based US physician respondents with complete data for variables of interest. After controlling for other factors, MIPS participation was associated with greater odds of spending a greater number of hours on after-hours documentation (odds ratio = 1.44, 95% confidence interval 1.06-1.95).

CONCLUSIONS

MIPS participation may increase after-hours documentation burden among US office-based physicians, suggesting that physicians may require additional resources to more efficiently report data.

Primary care physicians' electronic health record proficiency and efficiency behaviors and time interacting with electronic health records: a quantile regression analysis

OBJECTIVE

This study aimed to understand the association between primary care physician (PCP) proficiency with the electronic health record (EHR) system and time spent interacting with the EHR.

MATERIALS AND METHODS

We examined the use of EHR proficiency tools among PCPs at one large academic health system using EHR-derived measures of clinician EHR proficiency and efficiency. Our main predictors were the use of EHR proficiency tools and our outcomes focused on 4 measures assessing time spent in the EHR: (1) total time spent interacting with the EHR, (2) time spent outside scheduled clinical hours, (3) time spent documenting, and (4) time spent on inbox management. We conducted multivariable quantile regression models with fixed effects for physician-level factors and time in order to identify factors that were independently associated with time spent in the EHR.

RESULTS

Across 441 primary care physicians, we found mixed associations between certain EHR proficiency behaviors and time spent in the EHR. Across EHR activities studied, QuickActions, SmartPhrases, and documentation length were positively associated with increased time spent in the EHR. Models also showed a greater amount of help from team members in note writing was associated with less time spent in the EHR and documenting.

DISCUSSION

Examining the prevalence of EHR proficiency behaviors may suggest targeted areas for initial and ongoing EHR training. Although documentation behaviors are key areas for training, team-based models for documentation and inbox management require further study.

CONCLUSIONS

A nuanced association exists between physician EHR proficiency and time spent in the EHR.

Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial

BACKGROUND

This is the first randomized controlled trial evaluating the impact of note template design on note quality using a simulated patient encounter and a validated assessment tool.

OBJECTIVE

To compare note quality between two different templates using a novel randomized clinical simulation process.

DESIGN

A randomized non-blinded controlled trial of a standard note template versus redesigned template.

PARTICIPANTS

PGY 1-3 IM residents.

INTERVENTIONS

Residents documented the simulated patient encounter using one of two templates. The standard template was modeled after the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment, and deemphasized less useful elements.

MAIN MEASURES

Note length; time to note completion; note template evaluation by resident authors; note evaluation by faculty reviewers.

KEY RESULTS

36 residents participated, 19 randomized to standard template, 17 to new. New template generated shorter notes (103 vs 285 lines, p < 0.001) that took the same time to complete (19.8 vs 21.6 min, p = 0.654). Using a 5-point Likert scale, residents considered new notes to have increased visual appeal (4 vs 3, p = 0.05) and less redundancy and clutter (4 vs 3, p = 0.006). Overall template satisfaction was not statistically different. Faculty reviewers rated the standard note more up-to-date (4.3 vs 2.7, p = 0.001), accurate (3.9 vs 2.6, p = 0.003), and useful (4 vs 2.8, p = 0.002), but less organized (3.3 vs 4.5, p < 0.001). Total quality was not statistically different.

CONCLUSIONS

Residents rated the new note template more visually appealing, shorter, and less cluttered. Faculty reviewers rated both note types equivalent in the overall quality but rated new notes inferior in terms of accuracy and usefulness though better organized. This study demonstrates a novel method of a simulated clinical encounter to evaluate note templates before the introduction into practice.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04333238.

Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review

OBJECTIVE

Despite the widespread and increasing use of electronic health records (EHRs), the quality of EHRs is problematic. Efforts have been made to address reasons for poor EHR documentation quality. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or paper documentation. The purpose of this systematic review was to assess the effectiveness of interventions seeking to improve EHR documentation within an inpatient setting.

MATERIALS AND METHODS

A search strategy was developed based on elaborated inclusion/exclusion criteria. Four databases, gray literature, and reference lists were searched. A REDCap data capture form was used for data extraction, and study quality was assessed using a customized tool. Data were analyzed and synthesized in a narrative, semiquantitative manner.

RESULTS

Twenty-four studies were included in this systematic review. Owing to high heterogeneity, quantitative comparison was not possible. However, statistically significant results in interventions and affected outcomes were analyzed and discussed. Education and implementation of a new EHR reporting system were the most successful interventions, as evidenced by significantly improved EHR documentation.

DISCUSSION

Heterogeneity of interventions, outcomes, document type, EHR user, and other variables led to difficulty in measuring EHR documentation quality and effectiveness of interventions. However, the use of education as a primary intervention aligned closely with existing literature in similar fields.

CONCLUSIONS

Interventions implemented to enhance EHR documentation are highly variable and require standardization. Emphasis should be placed on this novel area of research to improve communication between healthcare providers and facilitate data sharing between centers and countries.

PROSPERO Registration Number: CRD42017083494.

Development and Optimization of Clinical Informatics Infrastructure to Support Bioinformatics at an Oncology Center

Translational bioinformatics for therapeutic discovery requires the infrastructure of clinical informatics. In this chapter, we describe the clinical informatics components needed for successful implementation of translational research at a cancer center. This chapter is meant to be an introduction to those clinical informatics concepts that are needed for translational research. For a detailed account of clinical informatics, the authors will guide the reader to comprehensive resources. We provide examples of workflows from Moffitt Cancer Center led by Drs. Perkins and Markowitz. This perspective represents an interesting collaboration as Dr. Perkins is the Chief Medical Information Officer and Dr. Markowitz is a translational researcher in Melanoma with an active informatics component to his laboratory to study the mechanisms of resistance to checkpoint blockade and an active member of the clinical informatics team.

Reimagining What We Measure in Atherosclerosis-a "Phenotype Stack"

The term phenotype is so commonly used that we often assume that we each mean the same thing. The general definition, the set of observable characteristics of an individual resulting from the interaction of their genotype with the environment, is often left to the eye of the beholder. Whether applied to the multiple levels of biological phenomena or the intact human being, our ability to characterize, classify, and analyze phenotype has been limited by measurement deficits, computing limitations, and a culture that avoids the generalizable. With the advent of modern technology, there is the potential for a revolution in phenotyping, which incorporates old and new in structured ways to dramatically advance basic understanding of biology and behavior and to lead to major improvements in clinical care and public health. This revolution in how we think about phenotypes will require a radical change in the scale at which biomedicine operates with significant changes in the unit of action, which will have far-reaching implications for how care, translation, and discovery are implemented.

Electronic medical record implementation for a healthcare system caring for homeless people

Objective

Electronic medical record (EMR) implementation at centers caring for homeless people is constrained by limited resources and the increased disease burden of the patient population. Few informatics articles address this issue. This report describes Boston Health Care for the Homeless Program’s migration to new EMR software without loss of unique care elements and processes.

Materials and methods

Workflows for clinical and operational functions were analyzed and modeled, focusing particularly on resource constraints and comorbidities. Workflows were optimized, standardized, and validated before go-live by user groups who provided design input. Software tools were configured to support optimized workflows. Customization was minimal. Training used the optimized configuration in a live training environment allowing users to learn and use the software before go-live.

Results

Implementation was rapidly accomplished over 6 months. Productivity was reduced at most minimally over the initial 3 months. During the first full year, quality indicator levels were maintained. Keys to success were completing before go-live workflow analysis, workflow mapping, building of documentation templates, creation of screen shot guides, role-based phased training, and standardization of processes. Change management strategies were valuable. The early availability of a configured training environment was essential. With this methodology, the software tools were chosen and workflows optimized that addressed the challenges unique to caring for homeless people.

Conclusions

Successful implementation of an EMR to care for homeless people was achieved through detailed workflow analysis, optimizing and standardizing workflows, configuring software, and initiating training all well before go-live. This approach was particularly suitable for a homeless population.

The Use of Evidence-Based, Problem-Oriented Templates as a Clinical Decision Support in an Inpatient Electronic Health Record System

BACKGROUND

The integration of clinical decision support (CDS) in documentation practices remains limited due to obstacles in provider workflows and design restrictions in electronic health records (EHRs). The use of electronic problem-oriented templates (POTs) as a CDS has been previously discussed but not widely studied.

OBJECTIVE

We evaluated the voluntary use of evidence-based POTs as a CDS on documentation practices.

METHODS

This was a randomized cohort (before and after) study of Hospitalist Attendings in an Academic Medical Center using EPIC EHRs. Primary Outcome measurement was note quality, assessed by the 9-item Physician Documentation Quality Instrument (PDQI-9). Secondary Outcome measurement was physician efficiency, assessed by the total charting time per note.

RESULTS

Use of POTs increased the quality of note documentation [score 37.5 vs. 39.0, P = 0.0020]. The benefits of POTs scaled with use; the greatest improvement in note quality was found in notes using three or more POTs [score 40.2, P = 0.0262]. There was no significant difference in total charting time [30 minutes vs. 27 minutes, P = 0.42].

CONCLUSION

Use of evidence-based and problem-oriented templates is associated with improved note quality without significant change in total charting time. It can be used as an effective CDS during note documentation.

Improving Bridging from Informatics Theory to Practice

BACKGROUND

In 1962, Methods of Information in Medicine (MIM) began to publish papers on the methodology and scientific fundamentals of managing data, information, and knowledge in biomedicine and health care. Meeting an increasing demand for research about practical implementation of health information systems, the journal Applied Clinical Informatics (ACI) was launched in 2009. Both journals are official journals of the International Medical Informatics Association (IMIA).

OBJECTIVES

Based on prior analyses, we aimed to describe major topics published in MIM during 2014 and to explore whether theory of MIM influenced practice of ACI. Our objectives were further to describe lessons learned and to discuss possible editorial policies to improve bridging from theory to practice.

METHODS

We conducted a retrospective, observational study reviewing MIM articles published during 2014 (N=61) and analyzing reference lists of ACI articles from 2014 (N=70). Lessons learned and opinions about MIM editorial policies were developed in consensus by the two authors. These have been influenced by discussions with the journal's associate editors and editorial board members.

RESULTS

The publication topics of MIM in 2014 were broad, covering biomedical and health informatics, medical biometry and epidemiology. Important topics discussed were biosignal interpretation, boosting methodologies, citation analysis, health-enabling and ambient assistive technologies, health record banking, safety, and standards. Nine ACI practice articles from 2014 cited eighteen MIM theory papers from any year. These nine ACI articles covered mainly the areas of clinical documentation and medication-related decision support. The methodological basis they cited from was almost exclusively related to evaluation. We could show some direct links where theory impacted practice. These links are however few in relation to the total amount of papers published.

CONCLUSIONS

Editorial policies such as publishing systematic methodological reviews and clarification of possible practical impact of theory-focused articles may improve bridging.

Improving Bridging from Informatics Practice to Theory

BACKGROUND

In 1962, Methods of Information in Medicine ( MIM ) began to publish papers on the methodology and scientific fundamentals of organizing, representing, and analyzing data, information, and knowledge in biomedicine and health care. Considered a companion journal, Applied Clinical Informatics ( ACI ) was launched in 2009 with a mission to establish a platform that allows sharing of knowledge between clinical medicine and health IT specialists as well as to bridge gaps between visionary design and successful and pragmatic deployment of clinical information systems. Both journals are official journals of the International Medical Informatics Association.

OBJECTIVES

As a follow-up to prior work, we set out to explore congruencies and interdependencies in publications of ACI and MIM. The objectives were to describe the major topics discussed in articles published in ACI in 2014 and to determine if there was evidence that theory in 2014 MIM publications was informed by practice described in ACI publications in any year. We also set out to describe lessons learned in the context of bridging informatics practice and theory and offer opinions on how ACI editorial policies could evolve to foster and improve such bridging.

METHODS

We conducted a retrospective observational study and reviewed all articles published in ACI during the calendar year 2014 (Volume 5) for their main theme, conclusions, and key words. We then reviewed the citations of all MIM papers from 2014 to determine if there were references to ACI articles from any year. Lessons learned in the context of bridging informatics practice and theory and opinions on ACI editorial policies were developed by consensus among the two authors.

RESULTS

A total of 70 articles were published in ACI in 2014. Clinical decision support, clinical documentation, usability, Meaningful Use, health information exchange, patient portals, and clinical research informatics emerged as major themes. Only one MIM article from 2014 cited an ACI article. There are several lessons learned including the possibility that there may not be direct links between MIM theory and ACI practice articles. ACI editorial policies will continue to evolve to reflect the breadth and depth of the practice of clinical informatics and articles received for publication. Efforts to encourage bridging of informatics practice and theory may be considered by the ACI editors.

CONCLUSIONS

The lack of direct links from informatics theory-based papers published in MIM in 2014 to papers published in ACI continues as was described for papers published during 2012 to 2013 in the two companion journals. Thus, there is little evidence that theory in MIM has been informed by practice in ACI.