Note Bloat

Introduction

Electronic health records (EHRs) serve as a unifying source of data for clinical care, research, administrative work, billing, and compliance. Clinical documentation in the EHR has become increasingly complex and challenging to read, termed ‘note bloat’.1,2 In attempting to serve many roles, clinical documentation often ends up serving none optimally. In the present state, much of clinical documentation is highly redundant but still lacks clarity and may be difficult to read. This can result in decreased provider efficiency and productivity.

Goals of EHR Generated Documentation

Recognizing this problem, in 2015 the American College of Physicians convened their Medical Informatics Committee to publish a position paper on the goals of EHR generated documentation. The committee stated, “The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up.”3 However, despite efforts to re-invent clinical documentation for the modern era, much remains unchanged from the time of paper charts.4 Additionally, the digitalization of health records has created a tension between structured data, which are more easily interpreted by computers, and unstructured documentation formats which may increase readability.5 In this way, EHRs can be more difficult for a human to read than the paper charts that they replaced.

More recently, a push for more transparency and access to the health record by the patient has added yet another factor adding complexity to the EHR documentation priority conundrum. The 20th Century Cures Act has provisions to discourage information blocking to assure access to the record by the patient.7

Factors Contributing to Note Bloat

- Easily available templated notes, autofill, smart phrases

- Availability of copy & paste functionality

- Documentation requirements for reimbursement (medical complexity)

- Risk of malpractice lawsuit

Potential Solutions

- Integrating artificial intelligence to augment clinician efforts in documentation may relieve some of the burdensome task but has yet to have accomplished this goal.6

- Prevent adding data already present elsewhere in the EHR to clinical notes

- Collapsing or hiding parts of the clinical note that are rarely read

References

1. Ozeran L, Schreiber R. Reduce Burnout by Eliminating Billing Documentation Rules to Let Clinicians be Clinicians: A Clarion Call to Informaticists. Applied Clinical Informatics 2021;12:073-5.

2. Kahn D, Stewart E, Duncan M, et al. A Prescription for Note Bloat: An Effective Progress Note Template. Journal of Hospital Medicine 2018;13:378-82.

3. Kuhn T, Basch P, Barr M, Yackel T, Medical Informatics Committee of the American College of P. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med 2015;162:301-3.

4. Gillum RF. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age. Am J Med 2013;126:853-7.

5. Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011;18:181-6.

6. Lin SY, Shanafelt TD, Asch SM. Reimagining Clinical Documentation With Artificial Intelligence. Mayo Clin Proc 2018;93:563-5.

7. PUBLIC LAW 114–255 To accelerate the discovery, development, and delivery of 21st century cures, and for other purposes. . In: Congress t, ed.2016.

Submitted by Doug Challener