U.S.-based physicians spend much more time jotting down patients' clinical notes than physicians practicing overseas, according to research published in an editorial for theAnnals of Internal Medicine.
After traveling to countries like Australia and Singapore, three physician researchers who have helped launch EHRs both at U.S. organizations and abroad noticed something peculiar: Physicians overseas were much more enthusiastic about potential improvements to patient care brought by digital systems. The researchers — Lance Downing, MD, clinical assistant professor of medicine at Stanford (Calif.) University; David Bates, MD, medical director of clinical and quality analysis, information systems, at Boston-based Partners HealthCare System; and Christopher Longhurst, MD, CIO of UC San Diego Health — then reviewed data from Epic to determine what could be overburdening U.S. physicians.
Here are three things to know.
1. U.S. medical regulations may be causing physicians to over-document in patient notes.
"Documentation in other countries tends to be far briefer, containing only essential clinical information," the research states. "It does not contain much of the compliance and reimbursement documentation that commonly bloats the American clinical note."
2. As physician burnout reaches crisis levels in the U.S., the researchers argue interaction with the EHR is contributing to their fatigue.
"While electronic health records have great potential to improve care, they may also have perverse effects," the research reads. "The highly-trained American physician, however, has become a data-entry clerk, required to document not only diagnoses, physician orders and patient visit notes, but increasingly low-value administrative data."
3. The researchers suggest simplifying current documentation requirements or allowing medical assistants to complete more of the charting could make much of the coding for tests and procedures unnecessary and thereby relieve some of the documentation burden. They add that new technologies, such as voice recognition software, could also show promise.
"Regulatory reform including changes to the billing requirements that allows clinicians to strip documentation to bare essentials, would improve accuracy, enable better use for research and reduce the tedious work that occupies so much of our time," the authors conclude.
Click here to download the editiorial.
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