Care-Centered Clinical Documentation in the Digital Environment: Solutions to Alleviate Burnout

Ommaya, Ayub K.; Cipriano, Pamela F.; Hoyt, David B.; Horvath, Keith A.; Tang, Paul C.; Paz, Harold L.; DeFrancesco, Mark S.; Hingle, Susan; Butler, S.D.; Sinsky, Christine A.

doi:10.31478/201801c

Cited by 45 publications

(33 citation statements)

References 40 publications

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“…With significant developments in fields of artificial intelligence and conversational analytics, health care will be transformed in the next decade; 35% of health care organizations plan to leverage artificial intelligence within 2 years and more than half intend to do so within 5 years [ 41 - 43 ]. Audiorecorded clinic data holds significant potential to tackle some of the major challenges we face today at lower costs, such as clinician documentation burden, patient recall of visit information, and improved patient-centered communication [ 44 ]. Highly accurate speech-to-text systems will enable real-time visit documentation [ 32 ]; patients and clinicians will once again be able to talk without the barrier of a computer.…”

Section: Discussionmentioning

confidence: 99%

Audio-/Videorecording Clinic Visits for Patient’s Personal Use in the United States: Cross-Sectional Survey

Barr¹,

Bonasia²,

Verma³

et al. 2018

J Med Internet Res

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BackgroundFew clinics in the United States routinely offer patients audio or video recordings of their clinic visits. While interest in this practice has increased, to date, there are no data on the prevalence of recording clinic visits in the United States.ObjectiveOur objectives were to (1) determine the prevalence of audiorecording clinic visits for patients’ personal use in the United States, (2) assess the attitudes of clinicians and public toward recording, and (3) identify whether policies exist to guide recording practices in 49 of the largest health systems in the United States.MethodsWe administered 2 parallel cross-sectional surveys in July 2017 to the internet panels of US-based clinicians (SERMO Panel) and the US public (Qualtrics Panel). To ensure a diverse range of perspectives, we set quotas to capture clinicians from 8 specialties. Quotas were also applied to the public survey based on US census data (gender, race, ethnicity, and language other than English spoken at home) to approximate the US adult population. We contacted 49 of the largest health systems (by clinician number) in the United States by email and telephone to determine the existence, or absence, of policies to guide audiorecordings of clinic visits for patients’ personal use. Multiple logistic regression models were used to determine factors associated with recording.ResultsIn total, 456 clinicians and 524 public respondents completed the surveys. More than one-quarter of clinicians (129/456, 28.3%) reported that they had recorded a clinic visit for patients’ personal use, while 18.7% (98/524) of the public reported doing so, including 2.7% (14/524) who recorded visits without the clinician’s permission. Amongst clinicians who had not recorded a clinic visit, 49.5% (162/327) would be willing to do so in the future, while 66.0% (346/524) of the public would be willing to record in the future. Clinician specialty was associated with prior recording: specifically oncology (odds ratio [OR] 5.1, 95% CI 1.9-14.9; P=.002) and physical rehabilitation (OR 3.9, 95% CI 1.4-11.6; P=.01). Public respondents who were male (OR 2.11, 95% CI 1.26-3.61; P=.005), younger (OR 0.73 for a 10-year increase in age, 95% CI 0.60-0.89; P=.002), or spoke a language other than English at home (OR 1.99; 95% CI 1.09-3.59; P=.02) were more likely to have recorded a clinic visit. None of the large health systems we contacted reported a dedicated policy; however, 2 of the 49 health systems did report an existing policy that would cover the recording of clinic visits for patient use. The perceived benefits of recording included improved patient understanding and recall. Privacy and medicolegal concerns were raised.ConclusionsPolicy guidance from health systems and further examination of the impact of recordings—positive or negative—on care delivery, clinician-related outcomes, and patients’ behavioral and health-related outcomes is urgently required.

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Section: Discussionmentioning

confidence: 99%

Audio-/Videorecording Clinic Visits for Patient’s Personal Use in the United States: Cross-Sectional Survey

Barr¹,

Bonasia²,

Verma³

et al. 2018

J Med Internet Res

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show abstract

“…More the checkboxes, radio-buttons or drop-downs, more will be the structured data. But the fall-out is that in the process of forcefully categorizing into one of the drop-downs or radio-buttons, the actual narrative of the patients' story is lost [19]. (Fig.…”

Section: Discussionmentioning

confidence: 99%

The information imperative: to study the impact of informational discontinuity on clinical decision making among doctors

Gowda

Kumar

Arya

et al. 2020

BMC Med Inform Decis Mak

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Background: Informational discontinuity can have far reaching consequences like medical errors, increased rehospitalization rates and adverse events among others. Thus the holy grail of seamless informational continuity in healthcare has been an enigma with some nations going the digital way. Digitization in healthcare in India is fast catching up. The current study explores the components of informational continuity, its impact on clinical decision-making and captures the general perception among the doctors towards a digital solution. Methods: Cross-sectional study with snowball sampling. A survey questionnaire was developed and validated through a pilot study, then circulated through online platforms. Responses from doctors were obtained through an online Google form for a period of 3 months and analyzed using SPSS 20. The categorical variables were analyzed using Chi-square test. Results: 1413 responses were obtained through a national level survey. Respondents were from a wide range of work experiences, locations, sectors, specialties and patient load. Components of patient records like clinical notes, investigation reports, previous diagnosis and treatment details were rated to be very important. 41% reported about half and 20% reported about 3/4th of their patients do not bring relevant records. Patients from rural areas, visiting state government hospitals and visiting general practitioners were less likely to bring relevant records during consultations. The fallouts of not having timely relevant patient information of the patients include more time per patient, repeat investigations, difficulty to arrive at definitive diagnosis, difficulty to take further treatment decisions and impaired overall clinical decision making which were said to be significant by respondents across the spectrum. The benefits of having timely relevant patient information were also reported consistently across the spectrum. An overwhelming proportion (83%), from across the spectrum, unequivocally expressed their willingness to use digital platforms for accessing patients' relevant medical records. Conclusion: Prevalence of informational discontinuity and its impact on clinical decision making is significant with definite benefits of having timely relevant medical history. There is strong willingness among the doctors to use digital solution(s) without any extra investment or effort on their part making customized solutions pertinent.

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“…2 Literature suggests that nurses spend as much as 50% of their day performing administrative tasks, including interacting with the medical record. 3 Redundant documentation and regulatory requirements contribute to documentation burden, 4 defined as the completion of unnecessary documentation elements in the electronic health record (EHR). 5 In an era where nurse leaders must demonstrate the value of nursing care to patient outcomes, it is more important than ever that data generated by nurses are useful in telling the patient story and highlight the unique contribution of nurses to that story.…”

Section: Significance Of the Problemmentioning

confidence: 99%

Defining an Essential Clinical Dataset for Admission Patient History to Reduce Nursing Documentation Burden

Sutton

Fogel²,

Giard³

et al. 2020

Appl Clin Inform

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Abstract Background Documentation burden, defined as the need to complete unnecessary documentation elements in the electronic health record (EHR), is significant for nurses and contributes to decreased time with patients as well as burnout. Burden increases when new documentation elements are added, but unnecessary elements are not systematically identified and removed. Objectives Reducing the burden of nursing documentation during the inpatient admission process was a key objective for a group of nurse experts who collaboratively identified essential clinical data elements to be documented by nurses in the EHR. Methods Twelve health care organizations used a data-driven process to evaluate inpatient admission assessment data elements to identify which elements were consistently deemed essential to patient care. Processes used for the twelve organizations to reach consensus included identifying: (1) data elements that were truly essential, (2) which data elements were explicitly required during the admission process, and (3) data elements that must be documented by a registered nurse (RN). Result The result was an Admission Patient History Essential Clinical Dataset (APH ECD) that reduced the amount of admission documentation content by an average of 48.5%. Early adopters experienced an average reduction of more than two minutes per admission history documentation session and an average reduction in clicks of more than 30%. Conclusion The creation of the essential clinical dataset is an example of combining evidence from nursing practice within the EHR with a set of predefined guiding principles to decrease documentation burden for nurses. Establishing essential documentation components for the adult admission history and intake process ensures the efficient use of bedside nurses' time by collecting the right (necessary) information collected by the right person at the right time during the patient's hospital stay. Determining essential elements also provides a framework for mapping components to national standards to facilitate shareable and comparable nursing data.

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Care-Centered Clinical Documentation in the Digital Environment: Solutions to Alleviate Burnout

Cited by 45 publications

References 40 publications

Audio-/Videorecording Clinic Visits for Patient’s Personal Use in the United States: Cross-Sectional Survey

Audio-/Videorecording Clinic Visits for Patient’s Personal Use in the United States: Cross-Sectional Survey

The information imperative: to study the impact of informational discontinuity on clinical decision making among doctors

Defining an Essential Clinical Dataset for Admission Patient History to Reduce Nursing Documentation Burden

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