EHRs can 'significantly' improve the quality of clinical notes

Electronic health records can improve the quality of physicians' clinical notes, according to an article in the Journal of the American Medical Informatics Association (JAMIA).

The researchers, from the Uniformed Services University of the Health Sciences in Maryland, conducted a five-year multicenter study of the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with Type 2 diabetes. The notes were evaluated six months before EHR implementation, six months after implementation, and five years after implementation, using an instrument called QNOTE.

The researchers found the note quality "significantly improved" over five years; with some of the notes improving in just the first six months after EHR implementation. The largest improvements were in problem lists, past medical history, social and family history and review of systems. There was a 30 percent improvement in core note quality, consisting of chief complaint, HPI, physical findings, assessment, plan of care and follow up.

Interestingly, the researchers declined to surmise why the notes improved, which would have been enlightening, although they do mention that EHRs utilize checkboxes, which is not always beneficial. The researchers also stressed that eliminating the ability of physicians to electronically cut and paste notes was not viable and that EHRs are also used for billing purposes, but did not tie these concepts to improved note quality. They pointed out that there currently is no standard to assess note quality, so there is currently no feasible way to provide physicians with feedback to improve their clinical notes.

EHRs have been found to be effective in a number of areas that directly affect patient care. However, as with any tool, their effectiveness is dependent to at least some extent upon how they are used.

To learn more:
- check out the study