September 14, 2015 Owen Carey

EHR Clinic Note Needs To Be More Physician-Friendly

It’s time to re-engineer the EHR Clinic Note to be more physician-friendly and better meet their needs, according to a studypublished by the Journal of the American Board of Family Medicine. This new study by researchers at the University of Missouri took a closer look at the utility of EHRs in regard to physician needs.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 precipitated the migration to EHRs, with approximately 78 percent of all office-based physicians now using the new record technology. And yet, according to previous research, only 38 percent of physicians are happy with the system, and many believe that they actually reduce efficiency and productivity of patient care, Science Daily reports.

As part of the study, Physician Information Needs and Electronic Health Records (EHRs): Time To Reengineer the Clinic Note, researchers observed primary care physicians using EHRs as part of their patient treatment process then asked them to identify the most and least important parts of the clinic note. Overwhelmingly, doctors reported the “assessment” and “plan” sections of the clinic notes to be the most important, while the “review of systems” section—which is required by Medicare and Medicaid for billing purposes—was deemed the least valuable.

“While EHRs have granted physicians access to more information than ever before, they also include lots of extraneous information that does not contribute to the care of the patient,” said Richelle Koopman, M.D., associate professor of family and community medicine at the MU School of Medicine and lead author of the study.

“Most physicians we observed skipped right to the assessment and plan sections, which include the diagnoses of the patient from the last visit and notes on how physicians planned to address the diagnoses,” Koopman said. “In addition, physicians expressed a lot of frustration about the poor utility of the ‘review of systems’ section and said it had little value in addressing patient care.”

One problem the study identified with the current EHRs is that they were cumbersome and repeated information, making them cluttered and difficult to navigate. One reason for the redundant information is the federal and regulatory demands regarding information.

The study concluded, “Current ambulatory progress notes present more information to the physician than necessary and in an antiquated format. “It is time to reengineer the clinic progress note to match the workflow and information needs of its primary consumer.”

Serving the Greater New York Area.

Get in touch with us !