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EHR 'Information Overload' Plagues Clinic Notes

 |  By Alexandra Wilson Pecci  
   September 17, 2015

Physicians feel frustrated and angry about what they describe as needless information that clutters patient notes in electronic medical records systems, research shows.

"If you want to get a physician angry and talking, get them to talk about their electronic health record," says Richelle Koopman, MD, associate professor of family and community medicine at the Missouri University School of Medicine.

It's no secret that discontent among doctors is widespread. A report released in 2013 by the American College of Emergency Physicians pointed to errors in patient care, attributed to electronic health record systems used in emergency departments, as "incredibly common." A year ago, the American Medical Association said physicians are "increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients" and called for a design overhaul of EHRs/EMRs.

Richelle Koopman, MD

Koopman is the lead author of a new study in the Journal of the American Board of Family Medicine showing that clinic notes in EHRs need a serious redesign if they're to be as useful as possible for physicians.

"We studied what information physicians need when they're about to see a patient and how they get that information that exists in the electronic health record," she says.

The researchers presented primary care physicians with fictitious patient notes for both an acute care visit (cough) and chronic care visit (type 2 diabetes, hypertension, hyperlipidemia, and depression) and watched them navigate through the EHRs/EMRs as though they were preparing for a patient visit. The physicians highlighted the parts of the note that they found important and unimportant, and researchers interviewed them about their choices.

The researchers found that the assessment and plan sections of the clinic notes were most important to physicians. These were the elements of the note that physicians reviewed first; they even jumped past other sections to get to this information.

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On the other hand, the "review of systems" section, a billing element required by Medicare, was not only considered the least important section, but was almost completely ignored by the physicians.

"They thought that that was largely extraneous, and in fact, it angered many of them because it took up so much space," Koopman says. Indeed, she says the "main theme" of the interviews and research findings were the strong emotions and frustration conveyed by the physicians.

The review of systems in particular was "a lightning rod for that anger" because it obscured information physicians actually needed. "That's a great recipe for frustration," she says. "Something that people feel is required, but doesn't really help them."

Poor Design
Koopman says part of the problem stems from the fact that EHRs/EMRs were originally designed to be familiar in look and feel to paper health records. Designs tried to mimic tabs for vital signs, medication lists, progress notes, test results, and other sections. As a result, users must click through different screens to access the sections that they need.

"That is a paper paradigm, and we have been slow in moving toward things like dashboards and Web capabilities," Koopman says. "Duplicating all of that information in the note doesn't really take into account the workflow that the physicians are now using."

She says other research has shown that dashboards are better for telling "the whole story in one screen."

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In addition, EHRs/EMRs prompt users to document a lot of things in the note, which create pages and pages of information that physicians often consider unnecessary.

Too Much Info
"There is all this documentation, and it tends to obscure the meat of the matter. So it's a problem of too much information," instead of quickly telling users what they need to know about the patient, Koopman says. She adds says that extraneous information in the EHR/EMR is not only troublesome to read, but also to generate.

"Putting all that together is a significant workload too," she says. "It's both about the organization and what needs to be there."

Having clear clinic notes and a clean, user-friendly EHR/EMR design is about more than simply making physicians' lives easier or alleviating physician complaints that using EHRs take up too much of their time. Too much EHR clutter and information overload makes physicians fear they may miss a piece of critical patient information.

"There are big concerns about what information is presented and how it should be presented. People feel like this is a very high-stakes safety issue, so it's very important to get it right," Koopman says. "If we can figure out the best way to make most salient points stand out clearly, that will be an important patient safety issue. It's not just about time at all."

Although EHR/EMR developers can view this study as a call to action, real change needs to "start with Medicare" because its requirements drive EHR design and documentation requirements," Koopman says.

"Medicare might need to revise the way it evaluates payment based on documentation," she says. "The more that we can make it easy [for physicians] to do the right thing because they're getting the right information, the better our EHRs/EMRs will be."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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