Interfacing With the Electronic Health Record (EHR): A Comparative Review of Modes of Documentation

Abstract

Electronic health records (EHRs) have provided physicians with a systematic framework for collecting patient data, organizing notes from the healthcare team, and managing the daily workflow in the modern era of healthcare. Despite these advantages, EHRs have proven to be problematic for clinicians. The burdensome regulations requiring increased documentation with the EHR paradigm have led to inefficiencies from dataentry requirements forcing physicians to spend an inordinate amount of time on it, affecting the time available for direct patient care as well as leading to professional burnout. As a result, new modalities such as speech recognition, medical scribes, pre-made EHR templates, and digital scribes [a form of artificial intelligence (AI) based on ambient speech recognition] are increasingly being used to reduce charting time and increase the time available for patient care. The purpose of our review is to provide an up-to-date review of the literature on these modalities including their benefits and shortcomings, to help physicians and other medical professionals choose the best methods to document their patient-care encounters efficiently and effectively.

Electronic Health Record for the Orthopaedic Providers

“…A comparative review from 2022 compiled data on medical documentation evolution and found that custom-built templates within the EHR system not only improved overall efficiency of patients seen per hour but also the quality of the documentation and patient satisfaction 11 . EHR systems can also provide easy access to patient information quickly, perhaps increasing the overall time spent with the patient and reducing duplicate tests and questions 10 .…”

Future Implications of Innovation in Gastroenterology for Clinical Practice: A Call to Action

“…Furthermore, novel software to reduce EHR burden will increase quality time spent in patient care and improve overall satisfaction. While integration of basic AI in clinical practices has begun, innovation has taken simple voice recognition software to clinic rooms with full voice-driven encounters, converted medical scribes to digital scribes, and added EHR templates to software, which can prepopulate entire visit notes and arrange a follow-up testing (4). These advances using AI are likely to make the greatest positive impact on day-to-day clinical practice.…”

Electronic nursing documentation interventions to promote or improve patient safety and/or quality care in an acute setting

“…This can be accomplished through the provision of information (Mehta, 2022). The ability of electronic nursing documentation to aid healthcare providers in being more productive and cost-effective is an additional significant advantage of this form of documentation (Avendano et al, 2022). The use of electronic nursing documentation comes with a number of benefits, this being one of them.…”