Ten EHR Strategies for Efficient Documentation

 

Applying even one of these 10 strategies can help you reduce frustration, improve productivity, and get home earlier.

Fam Pract Manag. 2020 Jul-Aug;27(4):5-10.

Author disclosure: no relevant financial affiliations disclosed.

© 2020 Jay Winner, MD, FAAFP

Many physicians consider electronic health record (EHR) documentation to be a main source of burnout.1 In fact, recent increases in physician burnout have coincided with the widespread adoption and use of EHRs. Even among those who aren't experiencing burnout, it's rare to find a doctor who is not experiencing some degree of frustration with the EHR. Poorly designed and poorly implemented EHRs are to blame, and continued advocacy is needed to improve these problems. In the meantime, there are strategies all physicians can use to become more efficient with electronic documentation — strategies that can help reduce frustration, improve productivity, and reduce work after clinic.

While not every strategy described in this article may be applicable to your practice, and you may already use others, if you find even one or two new strategies to help you get home a little earlier every day, reading this article will be time well spent.

KEY POINTS

  • Electronic health records (EHRs) are a major source of frustration and even burnout for physicians, but there are strategies physicians can use to make EHR documentation more efficient.

  • The overarching goal is to finish most, if not all, documentation during the visit so that you have little or no work after clinic.

  • Strategies include adopting a more efficient EHR setup in the exam room, using templates, smart phrases, and patient questionnaires, and writing shorter notes.

THE GOAL: FINISH MOST (IF NOT ALL) DOCUMENTATION DURING THE VISIT

Before I began using my current EHR system, my documentation routine was to take handwritten notes during a visit. At some point after the visit, I would dictate the visit, which would later be transcribed for documentation. If I was running behind, it was very easy for those dictations to stack up. At the end of a shift, I might have a half day of documentation to complete. At the end of particularly busy days, I might have almost an entire day of dictations left to do. Seeing a tall stack of charts and many undictated notes on my desk was, by far, my least favorite part of the day. Completing those notes was the task I most dreaded.

Today, when I finish the visit, my note is done. Those days of stacks of unfinished records are just bad memories. I spend less time documenting, and I get paid for more of my work. In the past, if I used CPT time-based coding, I could not count the extra five minutes of dictating that I completed after the patient left. Now, because I do all my documentation with the patient in the exam room, any time that I do spend is potentially billable.

Here are 10 strategies that have helped me become more efficient and could help you too, no matter which EHR system you use.

1. Rethink your exam room setup. Ideally, you should place the computer where you can alternate between

ABOUT THE AUTHOR

Dr. Winner is a family physician with Sansum Clinic in Santa Barbara and runs their stress-reduction classes. He is author of Relaxation on the Run and is adjunct clinical assistant professor of family medicine at the Keck School of Medicine, University of Southern California. He would like to acknowledge Dana Halverson, PhD, for her editorial assistance.

Author disclosure: no relevant financial affiliations disclosed.

© 2020 Jay Winner, MD, FAAFP

Reference

1. Landi H. Survey: physicians cite EHRs as biggest contributor to burnout. Healthcare Innovation. July 21, 2018. Accessed May 14, 2020. https://www.hcinnovationgroup.com/clinical-it/news/13030577/survey-physicians-cite-ehrs-as-biggest-contributor-to-burnout

 
 

Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

MOST RECENT ISSUE


Nov-Dec 2020

Access the latest issue
of FPM journal

Read the Issue


FPM E-Newsletter

Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights."

Sign Up Now