Best practices, model improve quality of EHR documentation

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The prospective trial targets “bloat” at four academic institutions, says Neveen El-Farra, MD.

Although the use of electronic health records by providers is almost universal, it has led to major challenges in the management of EHR documentation by physicians, who are more likely to include inaccurate, inconsistent and excessive information in the process. progress notes on patients.

The phenomenon is known as “grade bloat,” a nickname for the trend describing how doctors’ notes contain multiple pages of non-essential information, according to Neveen El-Farra, MD, associate professor of clinical medicine and associate dean. for Curricular Affairs to David Geffen of UCLA. Medicine School.

“The electronic health record makes it easy to import all of this data,” adds El-Farra, who is also a hospitalist in the department of medicine and associate program director of the internal medicine residency program. “EHRs were supposed to be the best things ever, but they have a lot of issues and are the number one cause of burnout among physicians. “

However, internal medicine residency programs at four academic institutions found that by encouraging physicians to document in the EHR only what is relevant for that day and limiting shortcuts, such as copy and paste and autocomplete. , the grades were significantly improved in terms of quality. and shorter overall. In addition, these practices reduced the time required for physicians to complete documentation.

Also look: Why the copy-paste functionality carries a significant risk

Inpatient internal medicine interns at UCLA, University of California San Francisco, University of California San Diego, and University of Iowa participated in prospective trial non-randomized who used a set of best practice guidelines and a template for progress notes. Grade quality was assessed based on an Overall Impression Score, Validated Physician Literature Quality Instrument 9-Item Version (PDQI-9), and a Competency Questionnaire.

“Significant improvements were seen in Overall Impression Score, all PDQI-9 domains, and several skill items including documenting relevant data only, discussing an exit plan, and doing be concise while being sufficiently comprehensive “, state the authors of the to study, which was published last week in the Journal of Hospital Medicine.

In addition, the study notes “had about 25% fewer lines and were signed an average of 1.3 hours earlier in the day,” according to the authors.

El-Farra and his co-authors observe that physicians typically spend a considerable amount of time writing notes in the EHR, so it was “encouraging to see that the post-intervention notes were signed 1.3 hours earlier today. “. She argues that this time saving could translate into more time spent in direct patient care.

Still, study data revealed variation between the four academic institutions, all of which use an Epic EHR, in the use of models: 92% at UCSF, 90% at UCLA, 79 % in Iowa and only 21% in UCSD. . Nonetheless, although UCSD reported low use of the model among its trainees, they still showed signs of improving the quality of grades in the study.

Since UCSF and UCLA created the guidelines and best practice model for the study, the authors suggest that the intervention could have been “better suited” to the cultures of their respective organizations and that they may have had more institutional buy-in from the start.

“We still have a long way to go,” admits El-Farra. “Some of our residents continue to use the note template; others don’t. We probably need to do a refresh, and that probably needs to be built into some sort of orientation for new interns so that they don’t hopefully become residents in the habits of cut and paste, notice bloating and import. simply data without synthesis and without thought process.

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