I had not time to make it shorter: an exploratory analysis of how physicians reduce note length and time in notes.

J Am Med Inform Assoc

Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.

Published: January 2023

Objective: We analyze observed reductions in physician note length and documentation time, 2 contributors to electronic health record (EHR) burden and burnout.

Materials And Methods: We used EHR metadata from January to May, 2021 for 130 079 ambulatory physician Epic users. We identified cohorts of physicians who decreased note length and/or documentation time and analyzed changes in their note composition.

Results: 37 857 physicians decreased either note length (n = 15 647), time in notes (n = 15 417), or both (n = 6793). Note length decreases were primarily attributable to reductions in copy/paste text (average relative change of -18.9%) and templated text (-17.2%). Note time decreases were primarily attributable to reductions in manual text (-27.3%) and increases in note content from other care team members (+21.1%).

Discussion: Organizations must consider priorities and tradeoffs in the distinct approaches needed to address different contributors to EHR burden.

Conclusion: Future research should explore scalable burden-reduction initiatives responsive to both note bloat and documentation time.

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Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9846677PMC
http://dx.doi.org/10.1093/jamia/ocac211DOI Listing

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