Appl Clin Inform 2019; 10(02): 247-253
DOI: 10.1055/s-0039-1683986
Research Article
Georg Thieme Verlag KG Stuttgart · New York

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

Laura Prater
1  Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Grandview, Ohio, United States
,
Anthony Sanchez
2  College of Medicine, The Ohio State University, Columbus, Ohio, United States
,
Gabriella Modan
3  Department of English, The Ohio State University, Columbus, Ohio, United States
,
Jennifer Burgess
3  Department of English, The Ohio State University, Columbus, Ohio, United States
,
Kim Frier
4  Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
,
Nathan Richards
3  Department of English, The Ohio State University, Columbus, Ohio, United States
,
Seuli Bose-Brill
1  Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Grandview, Ohio, United States
› Author Affiliations
Further Information

Publication History

21 November 2018

13 February 2019

Publication Date:
10 April 2019 (online)

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.

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.