Differences between when and how physicians document information in the EHR may lead to inefficiencies such as documenting too much or too little of the patient's information, according to a study published in the Journal of General Internal Medicine.
For the study, Ann Arbor-based University of Michigan researchers analyzed EHR data from 170,332 encounters led by 809 physicians from more than 200 healthcare practices. Additionally, researchers conducted interviews with a select group of 40 physicians to determine what EHR factors impact variation in documentation.
Researchers found that the following five clinical documentation categories presented substantial variation at the physician level:
1. Discussing results: 50.8 percent interquartile range and 78.1 percent physician-level variation.
2. Assessment and diagnosis: 60.4 percent IQR and 76 percent physician-level variation.
3. Problem list: 73.1 percent IQR and 70.1 physician-level variation.
4. Review of systems: 62.3 percent IQR and 67.7 percent physician-level variation.
5. Social history: 53.3 percent IQR and 62.2 percent physician-level variation.
Interview results showed that factors driving variation in clinical documentation were user preferences and EHR designs, which include multiple places to record similar patient information. These factors can risk patient safety by contributing to missed or misinterpreted patient data, the researchers wrote.
The research team concluded that while physician documentation preferences and EHR designs can each contribute to increased risk for patient harm, strategies such as enhanced user training during EHR implantation and adopting practice meetings to establish standardized documentation may help mitigate patient risk.