EHR documentation challenges remain
Thomas Payne, MD, FACP, attending physician in the General Internal Medicine Center at the University of Washington Medical Center-Roosevelt in Seattle, dictates notes into a recorder between patient appointments, recording notes on one patient before seeing the next.
He then uses speech-recognition software to move those recorded notes into his electronic health record (EHR) system.
Payne said his system ensures he gets to his notes quickly after each visit, and saves him time. “I do leave the clinic sooner than my colleagues do, by 30 minutes or so,” he said.
Although Payne acknowledged that his process “might not be the right choice for every primary care provider,” he does see an overall need to develop better practices around documentation.
“Documentation is one of the most time-consuming parts of a doctor’s day, particularly in primary care. It’s an area ripe for improvement,” said Payne, who is also medical director for IT services at the University of Washington School of Medicine and board chair for the American Medical Informatics Association (AMIA).
The rapid rise of EHRs has brought with it both changes and challenges in how physicians record and share their patient notes. Leaders in the medical community have found that when it comes to aiding documentation, the systems need to do a better job.
The Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs cited the need for EHRs to “simplify and speed documentation,” through other members of the care team entering the information, automatic data capture by devices or other information systems, and even having patients enter data themselves.
Payne said most EHRs aren’t designed to support documentation in a way that works well for physicians and their staff.
For example, he said many doctors record their notes in narrative form, writing down information that while not necessarily related to what brought a patient in for that particular visit is important to document the patient’s overall well-being.
However, Payne said most EHRs want doctors to check boxes or use drop-down fields to add details about a patient; EHRs generally can’t take the information recorded in narrative form and use it to populate the preset fields. That means doctors recording the same information multiple times, moving from one field to another on their computer screens.
“That’s not particularly satisfying nor is it the best use of that physician’s time,” Payne said.