Clinic notes should be re-engineered to meet needs of physicians

"While EHRs have granted physicians access to more information than ever before, they also includes lots of extraneous information that does not contribute to the care of the patient," said Richelle Koopman, M.D., associate professor of family and community medicine at the MU School of Medicine.

Koopman and her colleagues watched primary care physicians navigate through EHRs when preparing for patient visits and asked them to highlight what parts of the clinic note they found most and least important. Physicians overwhelmingly found the "assessment" and "plan" sections of clinic notes to be the most important and usually reviewed those first, while the "review of systems" section, which is required by Medicare and Medicaid for billing purposes, to be the least valuable information for patient care.

"Most physicians we observed skipped right to the assessment and plan sections, which include the diagnoses of the patient from the last visit and notes on how physicians planned to address the diagnoses," Koopman said. "In addition, physicians expressed a lot of frustration about the poor utility of the 'review of systems' section and said it had little value in addressing patient care."

During the transition from paper charts to EHRs, the system's creators mimicked what the paper charts looked like, which already were difficult to navigate due to increasing federal and regulatory demands on required information.

Koopman says early EHR documentation that mimicked the paper records led to a lot of redundant and cluttered information presented in an outdated fashion. She suggests patient information become more organized to allow physicians to spend more time with their patients instead of scrambling through notes to find the most valuable information. In addition, Koopman says her research supports the need to change the information needed for medical billing and says that a more streamlined way of presenting medical information can reduce medical errors that compromise patient safety.

In upcoming research, Koopman will work with Jeff Belden, MD, professor of family and community medicine at the MU School of Medicine, to discover the best way to organize patient information in clinical notes by using eye-tracking software to see how quickly physicians can find information using different clinical note prototypes they created.

Thomas Selva, M.D., chief medical information officer for MU Health Care, noted that the University of Missouri and the Tiger Institute for Health Innovation are national leaders in the development of better documentation tools.

According to Selva, numerous leading-edge tools that will facilitate the changes Koopman's research highlighted will be implemented at MU Health Care this year. Koopman's study, "Physician Information Needs and Electronic Health Records: Time to Reengineer the Clinic Note," was published by the Journal of the American Board of Family Medicine and was funded by Mizzou Advantage, an initiative that fosters interdisciplinary collaboration among faculty, staff, students and external partners to solve real-world problems.