EHR for Clinical Notes – An Analysis

EHR for Clinical Notes – An Analysis

Clinical notes are records that summarize the interaction between patients and healthcare providers, and are central to patient care. These may include notes from outpatient visits, inpatient admissions and discharges, procedures, protocols, and testing results. The process of documenting clinical care covers the diverse domains of patient care, clinical informatics, workflow, research and quality. As electronic health records (EHRs) are widely used by providers now, there is growing emphasis on structuring clinical notes to reuse data for subsequent tasks. However, generating clinical notes for an electronic record system is a challenging task. Before considering that, let’s take a look at how electronic health records improve the quality of clinical notes.

EHR and Quality of Clinical Notes Healthcare providers produce clinical documents to achieve several goals including: 

Create narrative reports that talk about their observations, impressions and actions related to patient care



Effectively communicate with collaborating healthcare providers



Clarify the level of service billed to third-party payers



Create a legal record in case of litigation



Provide data for clinical research and quality-assessment

Clinical notes not only influence patient care but also the financial, legal and research aspects of healthcare. The quality of clinical notes is therefore quite important.

Integrating clinical documentation system with EHR will: 

Enable a variety of documentation methods to contribute notes to the electronic record system



Allow all healthcare providers to view clinical notes in the electronic health records irrespective of the documentation system used in their own practice



Adopting a specific documentation method would not affect the completeness of data within the electronic record system

This will conjure up more comprehensive data and improve the quality of clinical notes. Further, a 2014 study published in the Journal of the American Medical Informatics Association confirmed that the use of EHRs improves the quality of clinical notes.

During the study, the handwritten notes and electronic notes of above 100 patients with Type 2 diabetes were compared. The notes were analyzed throughout the six months before the implementation of electronic health records, six months after the implementation and again after five years. They improved significantly, about 30 percent, over five years. Many notes that were in question improved within just six months after the implementation of new technology. The following areas have shown highly significant improvements: 

Overall note quality



Problem lists



Past medical histories



Social and familial histories



System reviews



Assessments



Plans of care and follow up

Challenges of Using EHR 

Checkboxes – Though checkboxes within an electronic record system are supposed to make it easier for physicians to generate detailed and comprehensive notes, they have some undesirable consequences - they let physicians briefly mention important aspects of notes that should have been more elaborate, and reduce the ability to assess the quality of the notes.

Complicated cases can generate complex notes that do not fit easily into these discrete boxes. This will leave physicians frustrated because they will

have to spend more time looking at the computer. Even though there may be larger boxes, information may be scattered throughout the note. 

Copy-pasting – Copying and pasting information from previous notes is a very old practice and it has become easier with electronic health record systems. This leads to indiscriminate copying and pasting within electronic health records in the pretext of saving time, and also results in bloated notes that

contain

redundant,

confusing,

outdated

and

sometimes

incorrect

information. At the same time, it is not a viable option to revoke the cut and paste functionality since there are several situations when crucial past information may have to be added to current note. The only way left to eliminate this practice is to evaluate clinicians’ notes and give them feedback regarding the quality.

Conclusion It is evident that electronic health records are inevitable to retain the quality of clinical notes. However, it is also important to address the challenges effectively. The best solution is to implement EHR transcription. In this approach, physicians’ dictations are transcribed with the help of skilled transcriptionists and the transcribed data is populated into the most appropriate fields through Discrete Reportable Transcription (DRT). This blended approach allows a third-party to evaluate the quality and ensure the comprehensiveness of data.