Variation in physician EHR documentation can put patient safety at risk: study

Doctor computer keyboard
Variation in how physicians document in the EHR can make it difficult for clinicians to find relevant information, potentially leading to patient harm. (Getty/jacoblund)

It's well documented that physicians are frustrated with the design of electronic health records (EHR) and the time they spend inputting information into the systems.

One major factor contributing to this inefficiency: the variation in how physicians document patient data.

This variation—which leads to physicians searching different places in the chart for information or documenting the same information multiple times—is impeding safe and effective use of EHRs, according to a study published in the Journal of General Internal Medicine.

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The researchers analyzed data of 170,000 patient encounters led by 800 physicians in 237 practices and also interviewed 40 physicians in 10 primary care practices. The study was led by researchers at the University of Michigan Health System, the University of Michigan Medical School and the Center for Clinical Informatics and Improvement Research at the University of California San Francisco.

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The research team found substantial variation in the documentation for five categories of clinical information as a result of optionality in the EHR design and varied implementation practices for the IT systems.

Rather than following best practices, physicians are documenting based on "idiosyncratic" choices facilitated by the multiple options available in the EHR to document each category of information, according to physicians who took part in the study.

As an example, during a patient exam, a problem or diagnosis can be documented in the review of systems, the problem list, the assessment and diagnosis, or in all three categories, according to the study.

This variation can lead to substantial costs for practices in the long run as it takes longer for physicians to find information, impacting the delivery of high-quality care, according to the study.

It also can lead to challenges with interpreting information, potentially causing patient harm as in the case of a physician missing a diagnosis by looking in the wrong field.

"Our results revealed that such variation jeopardizes the efficient and possibly safe delivery of care," the study authors said.

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The variation in how physicians document in the EHR is often due to physicians' preferences for structured or unstructured documentation, according to the physicians who took part in the study.

The medical director at one practice, who was also a practicing physician, explained that when documenting the history of present illness the EHR allowed users to choose between a structured template that would generate a note and an unstructured template with a single free-text field.

"It really depends on the provider whether they check more boxes or if they type more," the physician said, according to the study.

Allowing physicians to document either in free-text fields or via structured data entry gives the documenting physician more flexibility but impairs the ability of future users to search and find information, the study authors said.

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Many physicians pointed to a lack of training when the EHR system was first implemented that led to physicians documenting differently. One physician suggested that people developed different documentation behaviors in her practice because their training occurred entirely on video, instead of in-person.

These varying documentation styles can have substantial negative effects on the experience of documenting care, physicians said, such as over-documenting or putting the same information in multiple places to ensure future users could find the information.

In practices where users did not take extra time to complete documentation, the consequence was extra effort to search for information after the visit. As one physician noted, although these recurring inefficiencies were "only a few seconds, it adds up," according to the study.

And these inconsistencies with documentation, typically when documenting patient problems, interferes with the quality of care, physicians said.

As one physician noted, different preferences for maintaining the problem list created longer lists with "junk" information. "You may not know of something that’s important...if there’s a lot of irrelevant information," the physician said. "It makes it harder to know what’s a real problem versus what’s transient," according to the study.

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In contrast, physicians from a practice that perceived very little variation in EHR documentation attributed the consistency to clearly articulated documentation procedures learned during implementation.

The study authors provide several strategies for practices to mitigate these problems. Practices should focus on targeted user training during implementation to articulate the effects of documentation decisions and regular practice meetings to develop consensus around documentation.

However, these strategies are not in widespread use because variation in EHR documentation "manifests as small, frequent annoyances rather than substantial, salient problems," the study authors said.

Going forward, third-party stakeholders—in particular, payers and policymakers—may need to draw attention to the downstream costs of variation in EHR documentation and create incentives that motivate practices to pursue more standardized documentation.

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