U.S. doctors’ clinical notes 4 times as long as those in other countries

A doctor sitting at his desk working on a laptop computer.
Documentation requirements may be responsible for the fact that U.S. doctors' clinical notes are so long. (Getty/monkeybusinessimages)

Regulations that require doctors to document patient care may be responsible for the fact that U.S. physicians’ clinical notes are, on average, four times as long as those in other countries.

Those regulations may be causing U.S. physicians, who commonly complain about the time they spend on electronic health records (EHR), to overdocument when compared to their overseas counterparts, according to an opinion piece in the Annals of Internal Medicine.

"Documentation in other countries tends to be far briefer, containing only essential clinical information," the authors said. "It does not contain much of the compliance and reimbursement documentation that commonly bloats the American clinical note."

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And that may be part of the reason why the EHR is driving doctors’ dissatisfaction and burnout. Studies have found that U.S. doctors now spend as much time interacting with the computer as they do face-to-face with patients.

Primary care physicians are spending almost six hours a day on EHRs, both during and after clinic hours, according to research from the American Medical Association and the University of Wisconsin.

However, that complaint about EHRs isn’t mirrored in other countries, according to the three physician researchers, N. Lance Downing, M.D., of the Stanford University School of Medicine; David W. Bates, M.D., of Brigham and Women’s Hospital and Harvard Medical School; and Christopher A. Longhurst, M.D., of the University of California, San Diego.

The doctors, who have helped launch EHR software in hospitals in both the U.S. and abroad, said they noticed when they traveled overseas to places such as Australia and Singapore, doctors had a different attitude about the digital health records. Doctors there were excited about potential improvements to patient care, while U.S. doctors looked at the EHR as a burden.

“The receptivity seemed very different,” Downing, assistant professor of medicine and a biomedical informatics expert, told Stanford’s Scope.

When the authors looked further, they found that U.S. doctors, on average, do four times the amount of clinical note-taking as doctors in other countries, according to data collected by the EHR vendor Epic.

"While electronic health records have great potential to improve care, they may also have perverse effects," the authors wrote, suggesting they are contributing to the epidemic of physician burnout.

A serious problem for physicians, burnout is also an expensive one for the health systems they work for. A National Taskforce on Humanity in Healthcare report says burnout costs up to $1.7 billion a year in turnover among hospital-employed physicians.

“The highly trained American physician, however, has become a data-entry clerk, required to document not only diagnoses, physician orders and patient visit notes, but increasingly low-value administrative data,” the authors wrote.

So, what’s the answer? The researchers suggest simplifying current documentation requirements could make much of the coding associated with tests and procedures unnecessary and help alleviate the documentation burden. They also suggest allowing medical assistants to complete more of the charting to free up physicians’ time. They add that new technologies, such as voice recognition software, also show promise.

"Regulatory reform, including changes to the billing requirements that allows clinicians to strip documentation to bare essentials, would improve accuracy, enable better use for research and reduce the tedious work that occupies so much of our time," the authors conclude.

In fact, Kate Goodrich, M.D., chief medical officer at the Centers for Medicare & Medicaid Services, said earlier this year that 2018 is going to be a significant year for regulatory and burden reduction.

In a report released in February, the White House singled out the EHR reporting requirements as one reason that small physician groups and solo providers have been forced to merge with larger hospitals, stifling competition.

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