Researchers at Ohio State University in Columbus and OSU's Wexner Medical Center in Grandview have tackled a topic that will resonate with nearly all practicing family physicians: the art of documenting key components of a patient office visit in the EHR.
Specifically, the authors of a new study report set out to compare the content of recorded office visit conversations between physicians and their patients with the documentation entered into the patient's medical record. With a limited amount of time for each visit and many topics to discuss, exactly how do physician prioritize what is keyed into the patient's electronic record?
Research results are highlighted in an article titled "Electronic Health Record Documentation Patterns of Recorded Primary Care Visits Focused on Complex Communication: A Qualitative Study" that was published in the February issue of Applied Clinical Informatics. Nonsubscribers to that journal can access a research abstract online.(www.thieme-connect.com)
The authors noted -- and most physicians would agree -- that EHR documentation is more cumbersome and time-consuming than creating hand-written notes. That factor, coupled with packed appointment schedules and lots of patients with complex, multimorbid disease, leaves physicians in a precarious position when it comes to comprehensive documentation.
- New research shows that primary care clinicians often discuss social and emotional health topics with patients but fail to document them in the EHR.
- Primary care physicians know intimate details of their patients' lives and circumstances, but other clinicians who see them in a crisis situation may not have that perspective.
- Medical decisions and recommendations made without this information can make it difficult for the patient to comply with care plans.
Are time-constrained clinicians omitting pertinent social and emotional information from a patient's medical record -- details that could provide valuable insight to other clinicians when devising a care plan for that patient?
Co-author Seuli Brill, M.D., is an associate professor and director of research in the OSU Division of General Internal Medicine and is board-certified in internal medicine and pediatrics. She told AAFP News that as a primary care physician, she's had patients return to her after a hospitalization or a subspecialist consultation with a prescribed intervention that, unknown to the prescribing clinician, simply was not feasible for that patient.
As primary care physicians, "We know intimate details of our patients' lives and circumstances because we've been seeing them for 10-15 years. But other clinicians who are seeing them in a time of crisis, such as a new cancer diagnosis, may not have that perspective," said Brill.
The "hidden knowledge" primary care physicians hold needs to be disseminated, but the question is how and whether the medical record is serving that purpose, she added.
Corresponding author Laura Prater Ph.D., M.P.H., M.H.A., a postdoctoral researcher also in OSU's internal medicine division, said during a joint interview that the current study "was like peeling back the layers of the onion to determine if documentation mirrors actual communication or, if given the high demands on clinicians, certain things are prioritized."
Study Methods, Results
The research team analyzed transcripts and recordings collected from 10 unique patient-clinician encounters that occurred in 2016. All participating primary care practices were part of the same Midwestern medical center, and all used the same EHR system.
Patients had an average of 14 chronic problems, and patients' medical records listed an average of 12 prescribed medications. All clinicians specialized in internal medicine; nine were physicians and one was a nurse practitioner.
After analyzing the data, researchers grouped physician/patient discussion topics into categories defined as
- chronic conditions or any long-term, previously established condition that was considered an ongoing problem, such as diabetes or hypertension;
- acute/new problems that included either a recent problem of which the clinician was previously unaware or a complaint that had been treated and resolved;
- disease-prevention discussions that covered screening tests and vaccinations, such as a colonoscopy or pneumonia vaccination; and
- social and emotional health, including psychosocial topics such as a patient's work life, finances and emotions.
Key Findings, Conclusions
"Interestingly, we found that the majority of social and emotional health discussions went undocumented," but discussions that fell into the other three topic areas were documented consistently, wrote the authors.
Specifically, among the four topic conversation groups,
- chronic conditions were documented 90.4% of the time,
- preventive care, 88.9%,
- acute and/or new problems, 84.2%, and
- social and emotional health, just 30.6%.
Researchers also calculated the average length of conversations. Chronic topics led the list at nine minutes, seven seconds; preventive topics, five minutes, 59 seconds; social/emotional topics, five minutes, 49 seconds; and acute/new problems, three minutes, 33 seconds.
"We found that physicians were more likely to focus on the documentation of clinical complaints and less on social and emotional factors -- which have been shown to drive a patient's health care decision-making," wrote the authors.
Furthermore, they noted, "The results of our duration analysis for each topic show that clinicians are prioritizing communication regarding social and emotional topics, but not documentation."
Brill and Prater covered additional points in their interview, parts of which are condensed in this short Q&A.
Q. Why is this topic so important for primary care physicians to consider?
A. Brill: If we make medical decisions and medical recommendations in a void that doesn't take into consideration the real world that patients will be facing when they exit -- or the real perspectives or biases or fears that they have -- then we're not providing personalized medicine. And we aren't really engaging in shared decision-making because the patient's decision-making process is rooted in his or her reality.
Q. Did you encounter any unexpected findings?
A. Brill: Physicians intuitively know that issues around what's going on at home, what patients can afford and experiences of care within the family really matter when developing not just a therapeutic relationship, but an actual plan that the patient buys into. It seemed like the gap was more in getting those aspects of the visit onto paper.
Prater: Physicians honestly were spending a good amount of time on social and emotional topics in the encounters. So, it was surprising to me that although these weren't being documented as much, physicians were definitely spending almost six minutes per encounter talking about the components of social and emotional topics. The omission of these conversations in the EHR notes was not for lack of discussing them.
Q. What's the most important takeaway for family physicians?
A. Brill: Within that sacred role of primary care, the relational knowledge that the primary care doctor has of her patient is invaluable but often inaccessible by others; that knowledge needs to be relayed to the larger care team, especially with complex and vulnerable patients.
Prater: Fragmented care caused by a breakdown in communication can result in medical errors and gaps in decision-making across settings of care. And communicating social and emotional topics is just as important and highly relevant as communicating health-related topics such as chronic, acute and preventive topics.
Q. How can this research be used moving forward?
A. Brill: I hesitate to add more to the plate of physicians because as a primary care doc, I know we're stretched thin. But we all can advocate in different ways for improvement in the platforms we use so that it is not so labor-intensive to get across what we know about the patient. Documenting in the EHR involves a lot of clicks in a lot of different windows and fields.
And we can definitely document smarter to make sure we are relaying those valuable nuggets of information. So, if somebody is on a high-risk medication and can't get to their lab appointments, when I'm modifying the treatment plan based on that social circumstance, I might say, "Labs every three months rather than the ideal because it's infeasible for the patient to get transportation."
Prater: Or even saying something like "transportation barriers" for someone who has problems completing follow-up testing so that information is available to everyone on the whole care continuum. From a policy perspective, aligning incentives for providers to document these factors is important -- and even having payers do more to acknowledge the importance of counseling on social/emotional factors that may influence care.
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