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Weiner M, Flanagan ME, Ernst K, Cottingham AH, Rattray NA, Franks Z, Savoy AW, Lee JL, Frankel RM. Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs. BMC PRIMARY CARE 2024; 25:262. [PMID: 39026167 PMCID: PMC11264844 DOI: 10.1186/s12875-024-02501-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality. METHODS Patients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality. RESULTS Encounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points. CONCLUSIONS Among outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.
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Affiliation(s)
- Michael Weiner
- Center for Health Information and Communication, Department of Veterans Affairs, Health Services Research and Development Service, Veterans Health Administration, Richard L. Roudebush VA Medical Center, CIN 13 416, Indianapolis, IN, USA.
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc, 1101 West 10th Street, 46202-4800, Indianapolis, IN, USA.
| | - Mindy E Flanagan
- Center for Health Information and Communication, Department of Veterans Affairs, Health Services Research and Development Service, Veterans Health Administration, Richard L. Roudebush VA Medical Center, CIN 13 416, Indianapolis, IN, USA
| | - Katie Ernst
- Applied Decision Science LLC, Cincinnati, OH, USA
| | - Ann H Cottingham
- Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc, 1101 West 10th Street, 46202-4800, Indianapolis, IN, USA
| | - Nicholas A Rattray
- Center for Health Information and Communication, Department of Veterans Affairs, Health Services Research and Development Service, Veterans Health Administration, Richard L. Roudebush VA Medical Center, CIN 13 416, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc, 1101 West 10th Street, 46202-4800, Indianapolis, IN, USA
| | - Zamal Franks
- Center for Health Information and Communication, Department of Veterans Affairs, Health Services Research and Development Service, Veterans Health Administration, Richard L. Roudebush VA Medical Center, CIN 13 416, Indianapolis, IN, USA
| | - April W Savoy
- Center for Health Information and Communication, Department of Veterans Affairs, Health Services Research and Development Service, Veterans Health Administration, Richard L. Roudebush VA Medical Center, CIN 13 416, Indianapolis, IN, USA
- Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc, 1101 West 10th Street, 46202-4800, Indianapolis, IN, USA
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Joy L Lee
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Richard M Frankel
- Center for Health Information and Communication, Department of Veterans Affairs, Health Services Research and Development Service, Veterans Health Administration, Richard L. Roudebush VA Medical Center, CIN 13 416, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc, 1101 West 10th Street, 46202-4800, Indianapolis, IN, USA
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Feldman J, Goodman A, Hochman K, Chakravartty E, Austrian J, Iturrate E, Bosworth B, Saxena A, Moussa MM, Chenouda DM, Volpicelli F, Adler N, Weisstuch J, Testa P. Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: a Prospective Improvement Study. JMIR Form Res 2023; 7:e41223. [PMID: 36821760 PMCID: PMC10134024 DOI: 10.2196/41223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/23/2023] [Accepted: 02/15/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The introduction of electronic workflows has allowed for the flow of raw un-contextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete of clinically significant "signals". There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating. OBJECTIVE To describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation. METHODS This is a multi-hospital nonrandomized prospective improvement study conducted on the Inpatient General Internal Medicine Service across three hospital campuses at the New York University (NYU) Langone Health System. A group of physician leaders representing each campus met biweekly for six months. The output of these meetings included 1) a conceptualization of the note bloat problem as a dysfunction in information flow 2) a set of guiding principles for organizational documentation improvement 3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations and 4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience measured using the System Usability Scale (SUS). Primary outcomes measures after go-live include template utilization rate and note length in characters. RESULTS In usability testing amongst 22 medicine providers, the new progress note template averaged a usability score of 90.6/100 on the System Usability Scale. 77% of providers strongly agreed that the new template was easy to use. 68% strongly agreed that they would like to use the template frequently. In the three months after template implementation, General Internal Medicine providers wrote 65% of all inpatient notes with the new templates. During this period of time the organization saw a 46%, 47%, and 32% reduction in note length for general medicine progress notes, consults, and H&Ps, respectively, when compared to a baseline measurement period prior to interventions. CONCLUSIONS A bundled intervention that included deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency and patient outcomes. CLINICALTRIAL
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Affiliation(s)
- Jonah Feldman
- Medical Center Information Technology, NYU Langone Health, New York, US.,Department of Medicine, NYU Long Island School of Medicine, Mineola, US
| | - Adam Goodman
- Division of Gastroenterology & Hepatology, NYU Grossman School of Medicine, New York,, US
| | - Katherine Hochman
- Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US
| | - Eesha Chakravartty
- Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US.,Medical Center Information Technology, NYU Langone Health, New York, US
| | - Jonathan Austrian
- Medical Center Information Technology, NYU Langone Health, New York, US.,Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US
| | - Eduardo Iturrate
- Medical Center Information Technology, NYU Langone Health, New York, US.,Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US
| | - Brian Bosworth
- Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US
| | - Archana Saxena
- Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US
| | - Marwa M Moussa
- Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US
| | - Dina M Chenouda
- Department of Medicine, NYU Long Island School of Medicine, Mineola, US
| | | | - Nicole Adler
- Department of Medicine, New York University Langone Health, 550 1st avenue, New York, US
| | | | - Paul Testa
- Medical Center Information Technology, NYU Langone Health, New York, US
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