Spring 2024 Issue

Documentation Challenges
By Elizabeth S. Goar
For The Record
Vol. 36 No. 2 P. 10

Leveraging EHR Metrics to Alleviate Documentation Burden and Burnout

Increasingly stringent documentation requirements coupled with higher patient volumes, clinical staffing shortages, and clunky workflow processes have stretched physicians to their limits—and amped up the urgency around reducing documentation burden and associated burnout.

Many are quick to blame EHR systems and documenting in the patient’s EMR as root causes of documentation-associated burnout. Consider Medscape’s 2023 Physician Compensation Report, which found that nine of the 15 hours physicians spend each week on paperwork and administrative tasks goes toward documenting in the EHR.1 A JAMA Open Network study, “System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians,” found that primary care physicians spend a median of 6.2 minutes of after-hours time—aka pajama time—per patient visit working the EHR.2

Others are equally quick to note that there’s plenty of blame to share; that certain requirements would exist regardless of whether documentation is done electronically or on paper. Also, EHR benefits like analytics and ready access to patient information and clinical decision support often offset many of the negatives.

“There are a lot of different burnout drivers, and [EHRs are] just one of them. … Government regulations, quality indicators and billing processes all have increased the documentation burden. … You can’t just villainize [the EHR] 100%,” says Lisa MacLean, MD, chief clinical wellness officer for Henry Ford Health System, who adds that EHRs also provide “the ability to access information on patients. They can help to calculate health care trends, prevent human error, and improve patient care outcomes.”

The Heart of the Problem
To address documentation burden, it’s necessary to first understand its root causes. Doing so requires looking beyond the easy scapegoat—EHRs—to identify other contributing factors.

Documentation burden, according to R. David Allard, MD, chief medical informatics officer with Henry Ford Health System, is as much a technology and workflow issue as it is an environmental one. US clinical notes are twice as long as their European counterparts, in part because they must support billing and legal requirements in addition to clinical needs, he explains. As a result, the first contributing factor to documentation burden is the need for “large encyclopedic notes rather than relying on data packages from our systems to help us get a big picture.”

Next is the need for EHR technology capable of supporting those notes.

“Whether we’re going to create a really streamlined, spare note or a voluminous, inclusive note, technology needs to enable that,” Allard says. “Third is process. … You hear people say they wish their EMR was more like their smartphone; easy to use and they don’t have to think about it a lot. … The problem is that medicine is a complex set of data manipulations and thinking, so we need a lot of power.”

He likens the debate over EHRs and documentation burden to a boombox vs a sound studio mixing board. If only a few buttons are needed and the user is happy with the quality, then a boombox is sufficient. However, if documentation needs are complex, “then we’re going to need the sound studio mixing board,” he says. “[Striking] the balance between the boombox and the mixing studio is what we need [to do] and that’s where some of the art of informatics comes in.”

Dani Nordin, a product design architect with athenahealth and chair of the EHR Association’s User Experience Workgroup, says it’s difficult to blame EHRs exclusively for increased documentation burden if the sole measure is time spent in the system. Rather, she says, there are predictable variations in both workflow and encounter type that tend to have a greater impact.

For example, providers who have extremely routine encounters and can therefore take advantage of accelerators like encounter plans, templates, and macros can document far more quickly.

“I’ve seen orthopaedists document a full encounter in a minute and a half just by clicking and dictating, for example,” Nordin says. But “when you start getting into less routine cases—surgery, nursing documentation, or behavioral health documentation—where not as much can be standardized, documentation time is normally going to be longer because there’s less that can be templated.”

Who is doing the documenting must also be considered, she adds, as “many providers who perform a lot of procedures have multiple people contributing to their encounter documentation, which makes it impossible to accurately measure documentation time.”

This is not to say that EHRs are blameless. If documentation burden is evaluated based on the number of steps involved with note creation, one of the most time-consuming is reviewing what has been done before, Nordin says.

“That’s where EHR systems—especially for providers receiving data from many different sources that is poorly formatted, uncurated, and badly labeled—can create significant burden,” she says. “This may not be seen in documentation time. It might be seen in the time it takes to prep for the day’s encounters. It might be seen in the amount of time other people, like medical assistants and nurses, are spending adding to the encounter note. It’s definitely seen in the amount of pajama time providers are spending prepping their charts for the next day, sitting on the couch at night.”

Allard also considers the cognitive burden created by the need to navigate within the EMR to complete a note—an EHR contribution to documentation burden. “If I have to bounce around the chart … to find that [information] and drop or type it into my note, that extra little bit of movement causes some cognitive burden,” he says.

Documentation Data in the EHR
Ironically, despite shouldering much of the blame for increased documentation burden, recent research indicates that EHRs may hold the key to alleviating physician burnout associated with documentation overload.

In “Trends in Electronic Health Record Capabilities for Tracking Documentation Time,” published in the American Journal of Managed Care, researchers with the Office of the National Coordinator for Health Information Technology (ONC) examined how hospitals access and use EHR data to quantify the amount of time clinicians spend documenting clinical care in EHRs.3

The study was inspired by the rise in physician burnout and staff turnover and research pointing to “the increased adoption and use of EHRs as the culprit,” says Chelsea Richwine, PhD, lead researcher and ONC economist. “In response, EHR developers started creating tools to track the time clinicians spend documenting in their EHRs.”

These include measures that track burdensome activities—the most time-consuming EHR activities—as well as idle time, pajama time, and other measures that may provide better insights into what is contributing to documentation burden.

Richwine and her colleagues surveyed US acute care hospitals from 2017 to 2019 and in 2021, identifying the share of facilities that had access to EHR documentation time measures. They also looked at how access varied by hospital and EHR characteristics, then described how data was used and whether use varied by EHR type.

They found that the share of hospitals with access to documentation time measures increased significantly between 2017 and 2021, when more than two-thirds reported having access. Lower-resourced hospitals (eg, critical access and rural hospitals), nonteaching hospitals, and hospitals with nonmarket-leading EHRs were less likely to report having access. The two most common uses of EHR data were identifying providers in need of training and support and identifying areas to improve clinical workflow.

“A notable finding is that a higher proportion of hospitals with access to measures used them for more purposes over time, suggesting their increased value,” Richwine says. “Ultimately, I think this is an important takeaway of the study; measures aren’t just more common, they are more commonly used, which we hope will translate to better outcomes for providers in the form of burden reduction and greater EHR usability.”

She notes that access and use by lower-resource hospitals increased over time, suggesting that smaller EHR developers are now adding these tools. This, in turn, provides these facilities with tools to help devise strategies for reducing documentation burden. For example, documentation time measures can be used to identify time-intensive activities for targeted training and other solutions, such as scribes, aimed at reducing associated burden, Richwine says.

Measures can also be used to monitor the success of interventions and identify burdensome activities that are unique to an organization or experienced by all. The latter information, Richwine says, “can be used to inform policy efforts to systematically reduce burden associated with certain activities, when possible,” pointing to the 2023 evaluation and management guidelines reducing required documentation as an example.

Analyzing the Right Metrics
Context matters when it comes to utilizing EHR documentation measures. According to Nordin, the value in tracking documentation time data comes from identifying outliers and concerning trends and understanding the steps involved in the process. This allows for the root cause analysis needed for meaningful improvements.

For example, tracking how long it takes for a nurse to complete documentation in one patient’s room before moving on to the next “may allow you to identify that a particular nurse takes twice as long as their peers to write a note, which could indicate perhaps they need additional training. Or if all nurses take about the same amount of time but it takes a lot longer than it should, perhaps there’s an issue in the EHR.”

However, looking only at the amount of time a clinician spends documenting in the EHR may set up an unfair comparison among providers, because the focus becomes making clinicians document faster and not about ways EHR systems can accelerate and improve the actual process, Nordin says.

“The way that most measurement strategies look at documentation time, they are only focused on the amount of time the clinician is spending on the computer typing, clicking, or dictating—not the many other steps that are involved in doing that job. This creates unfair comparisons without considering, for example, whether this is an opportunity to recommend the use of accelerators to make documentation easier, or if there is a difference in the providers’ patient loads or case complexity,” she says.

It also tends to overlook one of the most significant burdens; sifting through documentation generated by various systems to find the pieces of information needed to write the note. That’s critical, Nordin says, because while EHR vendors can create accelerators, templates, and smart phrases, such tools do not help when it’s time to review documentation at the patient’s next encounter.

“Rather than emphasizing how quickly a note can be created, which is often done by using templates and other accelerators, there is tremendous value in evaluating the note that is created and how usable it is by the provider or external systems,” she says, adding that making documentation more consumable is an EHR Association’s User Experience Workgroup focus in 2024.

Henry Ford Focuses on Relief
Henry Ford Health has prioritized documentation-related physician burnout with implementation of several data-driven initiatives to address the issue and increase physician satisfaction. These include opportunities to improve EHR interactions to allow physicians to refocus their attention on patients and reduce pajama time.

“When your eyes are on the EMR and not on the patient, physicians feel like the thing that drives their satisfaction in their work is removed from the clinical encounter,” MacLean says. “When we used paper charts, we just documented what was happening with the patient. Now there are all these other things that we need to track that add so much more to the note and that takes a lot more time. There are also people in the background reviewing our notes … so we get paid for the work that we do. So, again, it’s a necessary evil.”

Henry Ford leverages metrics within its Epic EHR to track what time of day notes are created and how long it takes, which helps gauge the amount of pajama time. Also tracked are timeliness, whether notes are batched, and/or the average number of days it takes to complete a note.

“If you just take the length of time people spend in notes, that can be misleading depending on how busy the physician is,” Allard explains.

Measures can also be tracked against patient complexity. This includes tracking the number of notes created based on the average number of problems or average age. The system then benchmarks a patient’s complexity based on metrics, including order length, age, length of the problem list, and how much time providers spent in the EMR. This is also compared across specialties.

The idea is to monitor systemic goals such as whether clinicians are using available tools like macros and voice recognition to help accelerate documentation. “If we find that, overall, we’re really missing the boat and people aren’t using the tools we have available, then we try to beef up education around them,” Allard says.

For example, during the pandemic, the informatics team began distributing weekly 90-second videos with tips for improving documentation workflows. For those clinicians who need additional help, there’s a team dedicated to one-on-one training. Group classes are also available that focus both on tips and customizing documentation processes.

These methods are generally well-received, although Allard admits “it’s tricky. Sometimes doctors are so busy, they don’t want to take the time for the training that will save them time. … It’s a situation where ‘I’m too busy to make these macros that would save me tons of time.’ We all get on the treadmill sometimes and it’s just tough to get off. That’s in every industry; we’re not an exception.”

Henry Ford is testing the impact of newer tools, including a generative AI system that “listens” to conversations and interactions between clinicians and patients. Voice recognition creates a transcript that natural language processing turns into a list of concepts used by large language model AI to generate the clinical note.

Metrics are monitored to determine if the solutions “decrease pajama time, time per encounter, time to complete notes after the encounter, as well as provider satisfaction,” Allard says. “The other thing we have to check for, of course, is the quality of the note. It’s one thing to say the note is signed, but is it a good note? Is it accurate and comprehensible? Is it readable? Does it communicate what the next person who’s going to consume that note needs to know? That’s another piece of evaluation for these tools which are very new and evolving very quickly.”

Trial and Error
Finding ways to leverage EHR measures to alleviate documentation burden is very much an iterative process, MacLean says. She points to two projects undertaken by Henry Ford. One focused on physicians who don’t close encounter notes in a timely manner. The other was an educational toolkit that was customized based on a physician’s personal Signal report, which is generated by the Epic system and measures efficiency levels. Using the toolkit was meant to improve problematic efficiency markers.

There were two primary takeaways from the experiences, MacLean says. First, efficiencies won’t be improved by asking physicians to sacrifice more personal time to learn how.

“If we want to help people improve, we need to give them protected time to participate in additional training focused on enhancing their skills,” she says. “Number two, for people to close encounters and complete documentation in a timely manner, they need to learn to integrate completing documentation into the actual visit.”

MacLean points to research showing that physicians who do not complete documentation in real time are more likely to spend personal time documenting, have poor workplace integration, and be burned out. But while convincing physicians to shift their mindset to encompass more immediate documentation—something that can be supported by metrics within the EHR—can help, solving the problem requires looking beyond the technology or end user.

“Fixing the issue is complex, and it’s going to require change at multiple levels. We need to look at government regulations, hospitals, specific documentation guidelines, the complexity of the EHR itself, and then the end user,” she says. “For real change to occur there needs to be change at all of these levels. Health care is guilty of putting the major onus on the end user, but we can only become more efficient at documenting overall [by looking at] what the government requires, what a system might require, and how the EHR is designed.”

— Elizabeth Goar is a freelance health care writer in Wisconsin.

 

References
1. Kane L. 2023 physician compensation report. Medscape website. https://www.medscape.com/slideshow/2023-compensation-overview-6016341. Published April 14, 2023. Accessed February 13, 2024.

2. Rotenstein LS, Holmgren AJ, Horn DM, et al. System-level factors and time spent on electronic health records by primary care physicians. JAMA Netw Open. 2023;6(11):e2344713.

3. Richwine C, Patel V. Trends in electronic health record capabilities for tracking documentation time. Am J Manag Care. 2023;29(1):50-55.