Electronic Health Record Documentation Patterns of Recorded Primary Care Visits Focused on Complex Communication: A Qualitative Study

Abstract

Background In a time-constrained clinical environment, physicians cannot feasibly document all aspects of an office visit in the electronic health record (EHR). This is especially true for patients with multiple chronic conditions requiring complex clinical reasoning. It is unclear how physicians prioritize the documentation of health information in the EHR.

Objective The goal of this study is to examine documentation tradeoffs made by physicians when caring for complex patients by comparing the content of office visit conversations with resulting EHR documentation.

Methods We used grounded theory method of qualitative analysis to assess emergent themes in the transcripts of 10 office visits, and then compared the themes to documentation in the EHR. Differences between discussion and subsequent documentation of social and emotional health topics and each of the other key categories were compared using the Wilcoxon signed-rank test.

Results The categories that emerged included “chronic conditions,” “acute/new problems,” “disease prevention,” and “social and emotional health.” We found that when social and emotional topics were discussed in the office visit, it was documented in the medical record only 30.6% of the time. Chronic conditions, acute/new problems, and disease prevention were documented in the EHR between 87.5 and 91.7% of the time after discussion. The differences between discussion and documentation of social and emotional topics were significantly greater than the differences for chronic conditions, acute/new problems, and disease prevention (all p < 0.05).

Conclusion Social and emotional factors, while extremely relevant to health management, are less likely than medical concerns to be documented after discussion in an office visit. This lack of documentation may hinder interdisciplinary communication between teams informing individualized therapeutic decisions during acute care handoffs, such as outpatient to inpatient care.

Keywords

electronic health record - documentation - social determinants of health - multiple chronic conditions

Protection of Human and Animal Subjects

This study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by The Ohio State University Institutional Review Board.

• References

• 1 HIMSS. Electronic Health Records. 2018. Available at: https://www.himss.org/library/ehr/%3FnavItemNumber%3D13261 . Accessed November 5, 2018
• 2 Kern LM, Barrón Y, Dhopeshwarkar RV, Edwards A, Kaushal R. ; HITEC Investigators. Electronic health records and ambulatory quality of care. J Gen Intern Med 2013; 28 (04) 496-503
• 3 Wang SJ, Middleton B, Prosser LA. , et al. A cost-benefit analysis of electronic medical records in primary care. Am J Med 2003; 114 (05) 397-403
• 4 McCullough JS, Christianson J, Leerapan B. Do electronic medical records improve diabetes quality in physician practices?. Am J Manag Care 2013; 19 (02) 144-149
• 5 Romano MJ, Stafford RS. Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Arch Intern Med 2011; 171 (10) 897-903
• 6 Russo R, Fitzgerald SP, Eveland JD, Fuchs BD, Redmon DP. Improving physician clinical documentation quality: evaluating two self-efficacy-based training programs. Health Care Manage Rev 2013; 38 (01) 29-39
• 7 Hollingsworth JC, Chisholm CD, Giles BK, Cordell WH, Nelson DR. How do physicians and nurses spend their time in the emergency department?. Ann Emerg Med 1998; 31 (01) 87-91
• 8 Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc 2005; 12 (05) 505-516
• 9 Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. Health Aff (Millwood) 2004; 23 (02) 116-126
• 10 Joukes E, Abu-Hanna A, Cornet R, de Keizer NF. Time spent on dedicated patient care and documentation tasks before and after the introduction of a structured and standardized electronic health record. Appl Clin Inform 2018; 9 (01) 46-53
• 11 Østbye T, Yarnall KSH, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care?. Ann Fam Med 2005; 3 (03) 209-214
• 12 Centers for Disease Control and Prevention. Leading Indicators for Chronic Diseases and Risk Factors. 2015. Available at: https://chronicdata.cdc.gov/ . Accessed January 10, 2019
• 13 Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297 (08) 831-841
• 14 Elhauge E. , ed. The Fragmentation of U.S. Health Care: Causes and Solutions. Oxford University Press on demand; 2010
• 15 Sinnott C, Mc Hugh S, Browne J, Bradley C. GPs' perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open 2013; 3 (09) e003610
• 16 Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med 2009; 7 (02) 100-103
• 17 Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009; 47 (08) 826-834
• 18 Sharma R, Kostis WJ, Wilson AC. , et al. Questionable hospital chart documentation practices by physicians. J Gen Intern Med 2008; 23 (11) 1865-1870
• 19 Foy R, Hempel S, Rubenstein L. , et al. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Ann Intern Med 2010; 152 (04) 247-258
• 20 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380 (9836): 37-43
• 21 McCabe C. Nurse-patient communication: an exploration of patients' experiences. J Clin Nurs 2004; 13 (01) 41-49
• 22 Senteio C, Veinot T, Adler-Milstein J, Richardson C. Physicians' perceptions of the impact of the EHR on the collection and retrieval of psychosocial information in outpatient diabetes care. Int J Med Inform 2018; 113: 9-16
• 23 Guest G, Bunce A, Johnson L. How many interviews are enough?. Field Methods 2006; 18 (01) 59-82
• 24 Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine Publishing; 1967
• 25 Pagano M, Gauvreau K. Principles of Biostatistics. Belmont, CA: Duxbury; 2000
• 26 StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp; 2015
• 27 Tariman JD, Doorenbos A, Schepp KG, Becker PS, Berry DL. Patient, physician and contextual factors are influential in the treatment decision making of older adults newly diagnosed with symptomatic myeloma. Cancer Treat Commun 2014; 2 (2-3): 34-47
• 28 Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job?. Health Aff (Millwood) 2009; 28 (01) 64-74
• 29 Cockerham WC, Hamby BW, Oates GR. The social determinants of chronic disease. Am J Prev Med 2017; 52 (1S1, Suppl 1): S5-S12
• 30 Recommended Social and Behavioral Domains and Measures for Electronic Health Records. 2014. Available at: http://nationalacademies.org/hmd/~/media/Files/Report Files/2014/EHR-phase-2/EHRfindingsrecs.pdf . Accessed October 2018
• 31 CMS.gov. 2018 Program Requirements Medicare. 2018. Available at: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2018ProgramRequirementsMedicare.html . Accessed October 2018
• 32 Arcury TA, Quandt SA, Sandberg JC. , et al. Patient portal utilization among ethnically diverse low income older adults: observational study. JMIR Med Inform 2017; 5 (04) e47
• 33 Emani S, Ting DY, Healey M. , et al. Physician beliefs about the impact of meaningful use of the EHR: a cross-sectional study. Appl Clin Inform 2014; 5 (03) 789-801
• 34 Sinsky C, Colligan L, Li L. , et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med 2016; 165 (11) 753-760
• 35 Prodinger B, Rastall P, Kalra D, Wooldridge D, Carpenter I. Documenting routinely what matters to people: standardized headings for health records of patients with chronic health conditions. Appl Clin Inform 2018; 9 (02) 348-365
• 36 Fanucchi L, Yan D, Conigliaro RL. Duly noted: lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record. Appl Clin Inform 2016; 7 (03) 653-659
• 37 Misra-Hebert AD, Amah L, Rabovsky A. , et al. Medical scribes: how do their notes stack up?. J Fam Pract 2016; 65 (03) 155-159
• 38 Walker KJ, Wang A, Dunlop W, Rodda H, Ben-Meir M, Staples M. The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine. Appl Clin Inform 2017; 8 (03) 981-993
• 39 Stewart M, Brown JB, Donner A. , et al. The impact of patient-centered care on outcomes in family practice. J Family Practice 2000; 49 (09) 796-804
• 40 Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med 2011; 24 (03) 229-239
• 41 Franks P, Tancredi DJ, Winters P, Fiscella K. Including socioeconomic status in coronary heart disease risk estimation. Ann Fam Med 2010; 8 (05) 447-453
• 42 Adler NE, Stead WW. Patients in context--EHR capture of social and behavioral determinants of health. N Engl J Med 2015; 372 (08) 698-701
• 43 Gold R, Cottrell E, Bunce A. , et al. Developing electronic health record (EHR) strategies related to health center patients' social determinants of health. J Am Board Fam Med 2017; 30 (04) 428-447
• 44 DeVoe JE, Bazemore AW, Cottrell EK. , et al. Perspectives in primary care: a conceptual framework and path for integrating social determinants of health into primary care practice. Ann Fam Med 2016; 14 (02) 104-108
• 45 Epstein RM, Street Jr RL. The values and value of patient-centered care. Ann Fam Med 2011; 9 (02) 100-103
• 46 Stange KC, Nutting PA, Miller WL. , et al. Defining and measuring the patient-centered medical home. J Gen Intern Med 2010; 25 (06) 601-612
• 47 Sessums LL, McHugh SJ, Rajkumar R. Medicare's vision for advanced primary care new directions for care delivery and payment. JAMA 2016; 315 (24) 2665-2666