EHR Innovations for Healthier Patients and Happier Doctors
Early EHRs functioned mainly as a digital version of the Article chart and a tool to support charge capture. Even today, clinical encounter notes are designed to document content needed for reimbursement in a fee-for-service market. Many have criticized the quality of encounter notes generated by EHRs, stating notes are cluttered, redundant, irrelevant, duplicative, and at times spurious. Koopman et al used cognitive task analysis to simulate how clinicians prepare for an office visit to understand what information is needed from encounter notes. Clinicians identified narrative sections as having particular value, whereas check box sections and automatically cited content already available on summary dashboards had no value. The findings highlight a need to reengineer antiquated progress notes. Unlike prior paper-based notes that needed to summarize everything about a patient, electronic progress notes should be viewed as one data element in the patient's broader electronic record. This may reduce cognitive load, errors, and fatigue, as well as allow clinicians to focus more on the patient.
The Future of Electronic Documentation
Early EHRs functioned mainly as a digital version of the Article chart and a tool to support charge capture. Even today, clinical encounter notes are designed to document content needed for reimbursement in a fee-for-service market. Many have criticized the quality of encounter notes generated by EHRs, stating notes are cluttered, redundant, irrelevant, duplicative, and at times spurious. Koopman et al used cognitive task analysis to simulate how clinicians prepare for an office visit to understand what information is needed from encounter notes. Clinicians identified narrative sections as having particular value, whereas check box sections and automatically cited content already available on summary dashboards had no value. The findings highlight a need to reengineer antiquated progress notes. Unlike prior paper-based notes that needed to summarize everything about a patient, electronic progress notes should be viewed as one data element in the patient's broader electronic record. This may reduce cognitive load, errors, and fatigue, as well as allow clinicians to focus more on the patient.
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