Use of electronic clinical documentation: time spent and team interactions

Abstract

Care providers spend a significant amount of time viewing and authoring notes. Many notes are never read, and rates of usage vary significantly by author and viewer. While the rate of viewing a note drops quickly with its age, even after 2 years inpatient notes are still viewed.

How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers

“…This finding is higher than similar findings in previous reports (e.g., 21% of time spent on documentation 22,23 ), including a previous report from our institution. 24 This observation raises a question about whether electronic documentation is inevitably time-consuming and burdensome or whether there are limitations in the design of the current electronic documentation systems that inflate documentation time. This study may have highlighted several aspects of electronic documentation that contributed to inefficient use of time spent documenting.…”

Prioritizing Paperwork Over Patient Care: Why Can't We Do Both?

“…Unfortunately, whether due to constraints of having to rigorously and repeatedly document medical information or because of laxity, US providers are still not documenting clinical data accurately-thereby decreasing the utility of information being transferred. 24,25 With increasing volumes of paperwork and redundancy in data capture, resident and staff physicians are also less likely to review clinical documents in their entirety, 26,27 thereby increasing the risk of negligent behavior. Data are frequently automated via templates, which carries significant risk of inaccurate reporting due to falsely negative examination findings.…”

Racing Against the Clock: Internal Medicine Residents' Time Spent On Electronic Health Records

“…16 Automated tracking logs of screen time on the EHR provide objective data that minimize the error of human reporting. 17 Kuhn et al 18 and Clynch and Kellett 3 highlighted that increasing time spent on the EHR is due to a transition from its original role as a communication tool with a focus on patient care to a tool focused on regulatory compliance, billing, auditing, and coding. Time has been spent on generating increasingly longer clinical notes in the past 2 decades, 2,18 some of which appear to never be read.…”

“…Time has been spent on generating increasingly longer clinical notes in the past 2 decades, 2,18 some of which appear to never be read. 17 Multiple studies have raised concern about the increased time physicians spend on documentation, 2,3,11,13 which consumes between 25% to 60% of resident physicians' time. 2,3,8,11,12,19 The purpose of our study was to quantify the amount of time first-year residents spend on electronic documentation, using a built-in time tracking program from our EHR, and then to compare this to objectively reported times published in the literature.…”