Subscribe to RSS
Clinician and Health Care Leaders' Experiences with—and Perceptions of—COVID-19 Documentation Reduction Policies and PracticesFunding The 25 × 5 Symposium was supported through the U.S. National Library of Medicine (NLM) grant 1R13LM013581-01 and co-sponsored by AMIA. The co-authors are also supported through training grants from the NLM 5T15LM007079 and the National Institute for Nursing Research (NINR) 5T32NR007969.
Background Substantial strategies to reduce clinical documentation were implemented by health care systems throughout the coronavirus disease-2019 (COVID-19) pandemic at national and local levels. This natural experiment provides an opportunity to study the impact of documentation reduction strategies on documentation burden among clinicians and other health professionals in the United States.
Objectives The aim of this study was to assess clinicians' and other health care leaders' experiences with and perceptions of COVID-19 documentation reduction strategies and identify which implemented strategies should be prioritized and remain permanent post-pandemic.
Methods We conducted a national survey of clinicians and health care leaders to understand COVID-19 documentation reduction strategies implemented during the pandemic using snowball sampling through professional networks, listservs, and social media. We developed and validated a 19-item survey leveraging existing post-COVID-19 policy and practice recommendations proposed by Sinsky and Linzer. Participants rated reduction strategies for impact on documentation burden on a scale of 0 to 100. Free-text responses were thematically analyzed.
Results Of the 351 surveys initiated, 193 (55%) were complete. Most participants were informaticians and/or clinicians and worked for a health system or in academia. A majority experienced telehealth expansion (81.9%) during the pandemic, which participants also rated as highly impactful (60.1–61.5) and preferred that it remain (90.5%). Implemented at lower proportions, documenting only pertinent positives to reduce note bloat (66.1 ± 28.3), changing compliance rules and performance metrics to eliminate those without evidence of net benefit (65.7 ± 26.3), and electronic health record (EHR) optimization sprints (64.3 ± 26.9) received the highest impact scores compared with other strategies presented; support for these strategies widely ranged (49.7–63.7%).
Conclusion The results of this survey suggest there are many perceived sources of and solutions for documentation burden. Within strategies, we found considerable support for telehealth, documenting pertinent positives, and changing compliance rules. We also found substantial variation in the experience of documentation burden among participants.
A. J. M., S. C. R., and J. M. S. initiated the project, methods, and analysis plan. A. J. M. drafted the manuscript and conducted the quantitative analysis. A. J. M. and J. W. conducted the qualitative analysis. J. M. S. and A. J. M. led the survey development and distribution. J. M. S., E. L., K. D. C., J. W., J. M., S. T. R., and S. C. R. contributed to edits. All members of the 25 × 5 Steering Committee contributed as authors, tested the survey instrument, provided conceptual feedback, and approved the final manuscript.
Protection of Human and Animal Subjects
The 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 Columbia University Irving Medical Center Institutional Review Board.
Received: 20 July 2021
Accepted: 30 September 2021
24 November 2021 (online)
© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 HealthIT.gov. Strategy on reducing burden relating to the use of health IT and EHRs [Internet]. Cited June 20, 2020 at: https://www.healthit.gov/topic/usability-and-provider-burden/strategy-reducing-burden-relating-use-health-it-and-ehrs
- 2 Arndt BG, Beasley JW, Watkinson MD. et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017; 15 (05) 419-426
- 3 Sinsky C, Colligan L, Li L. et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016; 165 (11) 753-760
- 4 Roumeliotis N, Parisien G, Charette S, Arpin E, Brunet F, Jouvet P. Reorganizing care with the implementation of electronic medical records: a time-motion study in the PICU. Pediatr Crit Care Med 2018; 19 (04) e172-e179
- 5 Schenk E, Schleyer R, Jones CR, Fincham S, Daratha KB, Monsen KA. Time motion analysis of nursing work in ICU, telemetry and medical-surgical units. J Nurs Manag 2017; 25 (08) 640-646
- 6 Yen PY, Kellye M, Lopetegui M. et al. Nurses' time allocation and multitasking of nursing activities: a time motion study. AMIA Annu Symp Proc 2018; 2018: 1137-1146
- 7 Collins S, Couture B, Kang MJ. et al. Quantifying and visualizing nursing flowsheet documentation burden in acute and critical care. AMIA Annu Symp Proc 2018; 2018: 348-357
- 8 Overhage JM, McCallie Jr D. Physician time spent using the electronic health record during outpatient encounters: a descriptive study. Ann Intern Med 2020; 172 (03) 169-174
- 9 Kroth PJ, Morioka-Douglas N, Veres S. et al. Association of electronic health record design and use factors with clinician stress and burnout. JAMA Netw Open 2019; 2 (08) e199609
- 10 Melnick ER, Dyrbye LN, Sinsky CA. et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc 2020; 95 (03) 476-487
- 11 Topaz M, Ronquillo C, Peltonen LM. et al. Nurse informaticians report low satisfaction and multi-level concerns with electronic health records: results from an international survey. AMIA Annu Symp Proc 2017; 2016: 2016-2025
- 12 Gluckman TJ, Vavricek JJ. Streamlining evaluation and management payment to reduce clinician burden. Circ Cardiovasc Qual Outcomes 2019; 12 (04) e005426
- 13 Kuhn T, Basch P, Barr M, Yackel T. Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med 2015; 162 (04) 301-303
- 14 Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med 2014; 12 (06) 573-576
- 15 Bachynsky N. Implications for policy: the Triple Aim, Quadruple Aim, and interprofessional collaboration. Nurs Forum 2020; 55 (01) 54-64
- 16 Reeves JJ, Hollandsworth HM, Torriani FJ. et al. Rapid response to COVID-19: health informatics support for outbreak management in an academic health system. J Am Med Inform Assoc 2020; 27 (06) 853-859
- 17 Grange ES, Neil EJ, Stoffel M. et al. Responding to COVID-19: the UW Medicine Information Technology Services experience. Appl Clin Inform 2020; 11 (02) 265-275
- 18 HHS.gov. Telehealth: delivering care safely during COVID-19 [Internet]. Available at: https://www.hhs.gov/coronavirus/telehealth/index.html. Cited April 24, 2021
- 19 Sinsky C, Linzer M. Practice and policy reset post-COVID-19: reversion, transition, or transformation?. Health Aff (Millwood) 2020; 39 (08) 1405-1411
- 20 Cuomo GA. No. 202.10: continuing temporary suspension and modification of laws relating to the disaster emergency. Available at: https://www.governor.ny.gov/news/no-20210-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency. Cited April 24, 2021
- 21 Qualtrics. Qualtrics XM // The Leading Experience Management Software. Qualtrics. 2021
- 22 AMIA. Informatics Professionals. Leading the Way [Internet]. Available at: https://www.amia.org/. Cited April 24, 2021
- 23 Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 2006; 29 (05) 489-497
- 24 Sengstack PP, Adrian B, David R-B, Boyd L, Davis A, Hook M. et al. The six domains of burden: a conceptual framework to address the burden of documentation in the electronic health record. Position Paper of the American Nursing Informatics Association Board of Directors. Available at: https://www.ache.org/-/media/ache/about-ache/corporate-partners/the-six-domains-of-burden_cerner-documentation.pdf. Cited May 1, 2021
- 25 Temesgen ZM, DeSimone DC, Mahmood M, Libertin CR, Varatharaj Palraj BR, Berbari EF. Health care after the COVID-19 pandemic and the influence of telemedicine. Mayo Clin Proc 2020; 95 (9S): S66-S68
- 26 Hincapié MA, Gallego JC, Gempeler A, Piñeros JA, Nasner D, Escobar MF. Implementation and usefulness of telemedicine during the COVID-19 pandemic: a scoping review. J Prim Care Community Health 2020; 11: 2150132720980612
- 27 Lee NT, Karsten J, Roberts J. Removing regulatory barriers to telehealth before and after COVID-10. Accessed August 22, 2021 at: https://www.brookings.edu/research/removing-regulatory-barriers-to-telehealth-before-and-after-covid-19/. Published May 2020
- 28 Lieneck C, Garvey J, Collins C, Graham D, Loving C, Pearson R. Rapid telehealth implementation during the COVID-19 global pandemic: a rapid review. Healthcare (Basel) 2020; 8 (04) 517
- 29 Johnson KB, Neuss MJ, Detmer DE. Electronic health records and clinician burnout: a story of three eras. J Am Med Inform Assoc 2021; 28 (05) 967-973