EHR Note-Taking Might Pose Problems for Patients

One of the biggest benefits of EHR is that it allows doctors to dictate notes into a patient file. And as any overworked physician will tell you, this one feature is an incredible time saver. It also helps cut down on errors caused by illegible handwriting.

Now a bit of bad news about dictation. It might be affecting quality of care in a negative way. According to a new study published May 19 in the Journal of American Medical Informatics Association, dictating is easier on doctors. But they often don’t pay as close attention to information and alerts in the EHR that are important to patient health.

The paper was profiled in American Medical News. And the results of the research were pretty surprising. Researchers evaluated 18,569 primary care visits, which involved 234 doctors. The researchers also evaluated over 188,000 patient notes for their patients.

They found that 62% of those physicians mostly used text-free notes, 29% used structured documentation, and 9% used dictation. Structured documentation is like a template doctors can use in their note-taking, that divides the notes into different sections.

The doctors that primarily used dictation were often older, had more patient visits, and were attending physicians.

According to the AMN write up, here’s what they found:

The main outcome measures were 15 coronary artery disease and diabetes measures that researchers assessed 30 days after the primary care visit. Quality measures were considered fulfilled if the information was present in specific EHR-coded fields.

Researchers found that quality of care was significantly worse on three outcome measures for doctors who dictated their notes compared with physicians who used the other two documentation styles. Those measures were antiplatelet medication, tobacco use documentation and diabetic eye exam.

For example, tobacco use status was documented in the EHR of 22% of patients who visited a doctor using dictation, data show. The measure was documented for 36% of patients who visited a doctor using free-text notes and for 38% of those who saw a doctor who used structured documentation.

According to the research, quality of care was best when doctors used structured note taking, compared to the other two options.

So what does this mean for you? Well, it’s an important consideration to take into account when thinking about your EHR system. You might want to encourage doctors to take advantage of the structured note-taking, even though it takes a bit more time than dictation. This paper does show that quality of care declined with free form notes and dictation, so the extra time spent is worth it.

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