- A new study in JAMA Network Open found inconsistencies between the way emergency department residents documented patient encounters in an EHR and what trained observers witnessed.
- In the study, 12 observers (including two physicians and 10 undergraduate students with an interest in medicine) shadowed nine physicians during 180 patient encounters in the emergency departments of two teaching hospitals, which weren't identified. They focused their observations on two parts of each encounter: the review of systems, where physicians ask patients about their symptoms, and the physical exam. The encounters were recorded.
- Residents documented a median of 14 systems (or organs in the body) as being discussed with patients during the review of systems portion of the encounter, while observers recorded a median of five systems, the study found. During the physical exams, physicians documented a median of eight systems examined per encounter, while observers noted a median of 5.5.
CMS has developed complicated rules and regulations about how to document a patient encounter to account for the severity and complexity of a patient case and the amount of time a physician spends working on it. But recognizing that the documentation rules may be burdensome and outdated, officials have said they are working on reforming the process.
Heavy documentation and charting workloads are a cause of provider burnout, which is a major concern to health systems, hospitals and medical groups because burnout can lead to worsening well-being for physicians and lower-quality patient care.
It's also costly for the healthcare industry. For example, a recent study published in the Annals of Internal Medicine calculated annual burnout costs between $2.6 billion and $6.3 billion, including costs from staff turnover, lower productivity and other factors.
Burnout is not the only consequence of complicated documentation requirements.
The study's authors note that CMS rules create unintended incentives for providers to maximize reimbursement from payers by documenting extensively.
This problem is compounded by a feature in some EHRs that allows providers to auto-populate required fields in the software when documenting, particularly for the review of systems and physical exam portions of a patient encounter, the study authors wrote. However, auto-populating can lead to inaccuracies if the data entered into the fields does not reflect the specific circumstances of a patient case.
Inaccurate documentation also increases the risk of patient safety issues, which can impact patient outcomes, providers' quality scores, reputation and revenues under value-based reimbursement models. Faulty documentation also exposes facilities to the risk of payer audits.
In an accompanying editorial, commentators from the Icahn School of Medicine at Mount Sinai note that studies analyzing the accuracy of electronic documentation are rare but necessary. "An improved understanding of the root cause of discrepancies between patient report and physician documentation will be helpful in detecting ways to prevent them in the future," they wrote.