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Restoring Meaningful Content to the Medical Record: Standardizing Measurement Could Improve EHR Utility While Decreasing Burden

Published:October 07, 2022DOI:https://doi.org/10.1016/j.mayocp.2022.07.007
      Electronic health records (EHRs) dominate clinicians’ time.
      • Melnick E.R.
      • Ong S.Y.
      • Fong A.
      • et al.
      Characterizing physician EHR use with vendor derived data: a feasibility study and cross-sectional analysis.
      This time on the computer is often not well spent: EHRs are known for their poor usability and clerical burden, producing “bloated” notes with patient narratives and clinical reasoning lost in a sea of extraneous data and text.
      • Rule A.
      • Bedrick S.
      • Chiang M.F.
      • Hribar M.R.
      Length and redundancy of outpatient progress notes across a decade at an academic medical center.
      Yet the EHR’s exact purpose in clinical practice and documentation remains conflicted, with billing and clerical roles often eclipsing communication and decision-making capabilities. When fully realized, the EHR has the potential to be a valuable resource that assists with several tasks: documenting patient narratives, physical findings, and test results; using patient-specific data, medical knowledge, and computational power to support sound medical decision-making; documenting the resultant care plans and the reasoning and assessments behind them; facilitating order entry and communication with patients and other clinicians; and efficiently organizing large-volume data to enhance research and population health tracking. Developing scientifically sound metrics to evaluate EHR use and note quality could help identify specific targets for EHR improvement and illuminate a path forward to an EHR that facilitates rather than impedes care, augments clinician reasoning and documentation, and offloads mundane tasks, thereby supporting sustained attention on patients, their complexity, and their humanity.
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