Keywords
electronic health record - documentation - social determinants of health - multiple
chronic conditions
Background and Significance
Background and Significance
The electronic health record (EHR) is a comprehensive and longitudinal health record
including patient data on demographics, progress notes, problems, medications, medical
history, and other detailed medical information.[1] The EHR was, in part, developed to help improve communication between providers,
and in this role it has shown mixed results in terms of cost savings and improved
quality outcomes.[2]
[3]
[4]
[5] Despite limitations arising from interoperability challenges, the EHR still serves
as the main platform for communication in interdisciplinary care teams and between
physicians, especially when these providers are spread out over different locations.[6]
Despite the EHR's usefulness, many providers find documentation requirements (complicated
by additional regulatory demands) have increased, occupying almost half of a physician's
time.[7] Despite documentation becoming more comprehensive with the switch from paper to
electronic medical records, it has also likely increased the amount of time spent
documenting.[8]
[9]
[10] The problem is amplified when treating patients with chronic conditions, for whom
providing guideline-based care in all scenarios would take more time than the practicing
physician has available for patient care.[11] Considering 67.7% of patients 65 years or older have at least two chronic conditions
in 2015, this issue is particularly significant with the aging U.S. population.[12]
In addition to the competing time priorities found in caring for the complex patient,
the provider must also take care to avoid fragmentation due to situations such as
having multiple providers, discontinuation of insurance coverage, and receiving services
across multiple settings of care, all of which have been shown to affect communication
and patient care outcomes.[13]
[14] A fragmented system can contribute to the loss of important information between
providers, leading to “depersonalization” of care as well as medical errors, gaps
in clinical decision-making, and reductions in patient adherence.[15]
[16]
[17] In an effort to mitigate communication gaps resulting from fragmented care, physicians
caring for patients in different medical environments (e.g., inpatient, subspecialty,
and primary care) increasingly rely on EHR documentation from other disciplines to
gain a more comprehensive picture of a patient's history to guide health management
decisions.[18]
[19]
Due to additional regulatory demands and trends impacting medical practice, EHR documentation
has become time-intensive; it can take physicians three times longer to record patient
information in the EHR compared with paper charts.[8] Time demands of EHR documentation, the growth in prevalence of complex, multimorbid
disease, and an increased focus on clinician productivity leading to shorter visit
times, limits the ability of physicians to comprehensively document all aspects of
the visit.[20] These limitations result in a system where individual clinicians exercise judgment
on priority areas necessitating documentation. Current literature inadequately describes
which aspects of office visits physicians choose to synthesize into a coherent story
in EHR documentation. This study was designed to explore this gap in knowledge by
comparing office visit conversations with resultant EHR documentation.
Objective
The goal of this study is to compare the content of recorded office visit conversations
between clinicians and patients with complex chronic disease with resulting EHR documentation
to observe how clinicians prioritize discussed topics for documentation.
Methods
This study involves the qualitative analysis of the transcripts and recordings from
10 complex patient–physician encounters gathered from primary care practices within
a large Midwestern medical center exclusively using the Epic EHR system, in 2016.
Previous studies investigating similar qualitative communications data have similarly
sized study samples.[21]
[22] The concept of saturation, when no new information is gleaned from the data, guided
our decision that 10 transcribed clinical encounters were adequate to address our
aim.[23] This study's 10 clinical encounters focused on complex cases with multimorbid disease
because these time-intensive encounters resulted in content-rich data for analysis.
Each of the 10 encounters was audio recorded and subsequently copied using detailed
transcription. Accuracy was verified by spot-checking transcripts to the recorded
encounters at 2-minute intervals by a member of the research team not responsible
for transcription. The clinical transcripts were analyzed using elements of grounded
theory method of qualitative data analysis as described by Glaser and Strauss.[24] Specifically, transcripts were read in their entirety and clinical topics were coded
as emergent themes. Following coding, categories based on these themes were constructed
and examples were defined for each theme. Next, the research team pulled each encounter's
corresponding progress note from the EHR, conducted a content analysis, and compared
the results of the transcript coding to the progress notes, using the emergent themes
from the transcripts. Percentage agreement was calculated between the content analysis
from the transcripts and the documentation in the EHR within each general theme. Additional
areas of the chart, such as the social history tab, were also searched to ensure complete
analysis of chart content from the relevant office visit. After individual analysis,
the two team members met to discuss, compare, and contrast their findings and impressions
of both data sources. In instances of disagreement between analysts regarding the
appropriate theme, agreement was eventually achieved through brief discussion. Microsoft
Word and Excel 2016 were used for transcription and coding.
We also quantitatively assessed the paired differences between discussion and subsequent
documentation in each of the key categories. The differences between social/emotional
discussion and documentation were compared with the differences between the discussion
and documentation of chronic conditions, preventive care, and acute conditions for
each of the patient/provider encounters using the Wilcoxon signed rank test. The Wilcoxon
signed rank test is a nonparametric method often used to compare two samples which
are not independent and which may violate the normality assumption of parametric methods.[25] Stata IC/version 14.2 was used for the analysis.[26]
Institutional Review Board approval was obtained prior to the commencement of the
study. Written informed consent was obtained from both the physician and patient prior
to the recorded visit. Digital files of the transcribed interviews were kept electronically
and were securely stored so that only appropriate members of the research team were
able to access the data.
Results
The study population consisted of 10 unique patient/provider pairs, as is seen in
[Table 1]. Of the patients, four were male and six female, with an average age of 59 years
old. Patients had an average of 14 chronic problems and had an average of 12 prescribed
medications in their record. Of the 10 encounters, 6 providers were female and 4 providers
were male; 9 of these providers were medical doctors and 1 was a nurse practitioner.
All providers specialized in internal medicine.
Table 1
Patient/provider demographics
|
Patient/Provider demographics
|
|
Provider sex
|
6 female; 4 male
|
|
Patient race
|
9 white; 1 African American
|
|
Patient sex
|
4 male; 6 female
|
|
Average patient age
|
59
|
|
Average number of chronic conditions
|
14
|
|
Average number of medications
|
12
|
The categories that emerged included “chronic conditions,” “acute/new problems,” “disease
prevention,” and “social and emotional health.” The “chronic conditions” category
is used to classify any discussion related to a long-term condition that had been
previously established in past visits as an ongoing problem. Diseases that fall into
this category might include diabetes, hypertension, and hyperlipidemia. “Acute/new
problems” refers to discussions of either recent problems of which the provider was
previously unaware, or a complaint that was treated and subsequently resolved. “Disease
prevention” is used to classify discussions regarding vaccinations and screening tests,
such as a colonoscopy or a pneumonia vaccine. Finally, “social and emotional health”
classifies a variety of other discussions, particularly those that are focused on
a patient's social and work life, emotions, preferences, finances, and other psychosocial
topics.
Interestingly, we found that the majority of “social and emotional health” discussions
went undocumented. On the other hand, discussions regarding chronic conditions, new
and acute problems, and disease prevention were consistently documented. Across the
10 encounters, a total of 137 topics were discussed between the patients and providers,
averaging 14 topics per encounter. Of 73 total “chronic conditions” topics, 66 (90.4%)
were documented in the encounter's corresponding progress note. A similarly high percentage
of topics were documented for “acute/new problems” and “disease prevention”; results
showed 16 out of 19 (84.2%) and 8 out of 9 (88.9%) discussions were documented in
these categories, respectively. In contrast, of the 36 “social and emotional health”
topics discussed, only 11 (30.6%) of these details were documented in the corresponding
progress note. These results are described at the encounter level in [Table 2].
Table 2
Number of chronic, acute, preventive, and social/emotional topics documented after
discussion (documented/discussed)
|
Patient/Provider pair
|
Chronic conditions
|
Acute/New problems
|
Preventive
|
Social-emotional health
|
|
1
|
2/3
|
2/2
|
0/0
|
1/4
|
|
2
|
3/3
|
3/3
|
0/0
|
1/2
|
|
3
|
12/13
|
0/0
|
2/2
|
1/1
|
|
4
|
13/14
|
0/0
|
1/2
|
2/6
|
|
5
|
10/10
|
5/5
|
0/0
|
1/3
|
|
6
|
3/4
|
0/1
|
0/0
|
0/5
|
|
7
|
8/9
|
3/3
|
1/1
|
2/4
|
|
8
|
3/4
|
2/2
|
3/3
|
3/7
|
|
9
|
7/7
|
1/2
|
1/1
|
0/2
|
|
10
|
5/6
|
0/1
|
0/0
|
0/2
|
|
Total
|
66/73 (90.4%)
|
16/19 (84.2%)
|
8/9 (88.9%)
|
11/36 (30.6%)
|
Results from the Wilcoxon signed rank test tested the null hypothesis that the median
difference among pairs is equal to zero. We reject the null hypothesis and conclude
that the median difference between social/emotional documentation and discussion was
significantly greater than the median differences between the discussion and documentation
of chronic conditions (z = 2.57; p < 0.05), disease prevention (z = 2.92; p < 0.01), and acute conditions (z = 2.78; p < 0.01) across all encounters. Transcribed examples of discussions corresponding
to each of the four categories are present in [Table 3].
Table 3
Examples of topics addressed in office visits, by category
|
Topic
|
Example 1
|
Example 2
|
Example 3
|
|
Chronic
|
Doctor: “I actually would be interested to have you check your blood sugars two hours
after your meals and see where it's at” Patient: “Okay”
|
Patient: “Metformin- it gives me some gas, it's not horrible, I have to watch my carbohydrates
or I get gas”
|
Patient: “...headaches are rare now which I'm very thankful for…”
|
|
Acute
|
Doctor: “You had mentioned you were having some new shortness of breath”Patient: “Yeah”
|
Patient: “My finger is pink, it's tender”
|
Patient: “It started Saturday night I didn't feel…I just felt really tired, and then
Sunday I woke up... I was really sick...”
|
|
Preventative
|
Doctor: “Also you need your third Hep B vaccination”Patient: “Okay”
|
Doctor: “Just like the flu vaccine there are always potential side effects”Patient:
“Can we wait”Doctor: “Of course”
|
Doctor: “There's a recommendation for a new pneumonia vaccine, it's not new on the
market, but new for older folks”
|
|
Social/Emotional
|
Patient: “I mean I am not kidding you like last weekend I literally lay in bed and
I cried I'll bet you for five–six hours straight”
|
Patient: (on suicidal ideation) “Yeah the mental thing too, it's like there's days
where I honestly…I thought about it”
|
Patient: “I think we're gonna lose our health insurance and our prescription coverage
through (company name) we got a letter the other day…”
|
[Table 4] displays the total time spent discussing each topic across all 10 encounters, as
well as the average time spent discussing each topic. On average, chronic topics were
discussed for the longest amount of time per encounter (9:07), followed by similar
durations for preventive topics (5:59) and social/emotional topics (5:49), and finally
acute topics (3:33).
Table 4
Total and average time spent discussing each topic
|
Social/Emotional (min:s)
|
Acute (min:s)
|
Chronic (min:s)
|
Preventative (min:s)
|
|
Total time (range)
|
58:10 (0:31–11:28)
|
35:28 (0:00–8:29)
|
91:11 (2:11–16:03)
|
29:45 (0:00–13:24)
|
|
Average time per encounter
|
5:49
|
3:33
|
9:07
|
5:59
|
Discussion
Our primary finding that social and emotional topics are less likely to be documented
after discussion, relative to acute, chronic, and/or preventative topics, is not consistent
with documenting a holistic history of the patient's health. 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.[27] Social determinants of health have a significant impact on the management of chronic
and acute conditions, making them especially relevant for care planning.[28] Patients with multiple chronic conditions are very likely to have social determinants
that could impact the development and management of their health status.[29] For example, patients living in more socioeconomically deprived areas not only had
a higher prevalence of mental health disorders such as depression, but also increased
numbers of physical health disorders and multimorbidity.[20]
The Institute of Medicine (IOM) recommends that EHRs capture information for 10 domains
of social determinants of health—4 of which are already regularly collected (race,
alcohol use, tobacco use, and address).[30] Stage three of the Center's for Medicare and Medicaid Services EHR Meaningful Use
program also used the IOM report to develop standards for health care providers on
the collection of social and demographic information in the EHR to establish meaningful
use of an EHR.[30] With substantial growth in value-based purchasing and alternative models of care
such as the Patient-Centered Medical Home (PCMH), the capture of social determinants
for patients will continue to grow in importance.
As the Meaningful Use program moves forward with updated goals reflected in their
new title (the “Promoting Interoperability” program), there will be an increased focus
on patient portal use and interoperability.[31] Providers must adapt by assessing a patient's readiness and willingness to communicate
via portal and by documenting relevant social characteristics in the EHR. Training,
engaging caregivers, and increasing access to technology in public settings have all
been identified as potential avenues for improving access and use of patient portals.[32] Engaging in these strategies with a patient will require a comprehensive assessment
of their social and emotional well-being as well as their acceptance of the technology.
Documentation of these conversations will be critical so that all members of the care
team are able to engage in care planning for the patient as this relationship becomes
more dependent on technology.
Based on the results from our study, clinicians generally did not prioritize the documentation
of social information in the studied patient encounters, despite the fact that they
spend more time discussing them than they do acute topics, and similar amounts of
time discussing preventive topics. The results of our duration analysis for each topic
show that clinicians are prioritizing communication regarding social and emotional topics, but not documentation. The root causes behind
this incongruity are not yet clearly defined in the literature. Existing research
shows that physicians tend to have negative perceptions regarding the Meaningful Use/Promoting
Interoperability program because of increased time demands for documentation.[33] National, multisite studies have shown that physician documentation burdens are
ubiquitous, with 2 hours of documentation spent for every hour of face-to-face patient
care in current primary care practice.[34] In light of these existing time demands, progress toward additional, detailed office
visit documentation will require EHR improvements allowing more facile documentation
and retrieval of detailed social history. Innovative and automated EHR-based solutions
that make it easier for providers to integrate social and emotional determinants of
health into routine care may eventually link documentation practices to improved outcomes
over time. Requirements of the Promoting Interoperability program make the development
and adoption of such technologies even more acutely necessary. Furthermore, patients
perceive that various social and emotional determinants, such as emotions, social
life, social activities, and finances, should be documented in the EHR.[35]
Improving documentation among physicians through educational intervention has reaped
little benefit,[36] perhaps due to the lack of compelling incentives in an already time-constrained
clinical environment. To make measurable improvement, interventions must work to offset
the burden of documentation, seamlessly integrate into current documentation workflows,
or provide incentives for clinicians. Scribes (who document on behalf of the physician)
have helped improve clinical efficiency in a team-based practice but more research
needs to examine their potential role in improving the quality of documentation. While
scribes may improve subjective quality of the documentation, studies have not assessed
objective quality in diverse care settings, or consistency of documentation with the
actual topics discussed in the encounter.[37]
[38] Holding more promise, is addressing a potential contributing factor—the lack of
incentives. While there is an evidence base for improvements in outcomes with the
integration of a patient's social and emotional concerns in the form of patient-centered
care,[39]
[40]
[41] there are a lack of financial reimbursement mechanisms that would allow physicians
to justify spending time on these important components. Recommendations and frameworks
for the inclusion of social and behavioral data in the EHR, while a necessary start,
do little to assign accountability for incorporating an assessment of these measures
into the clinical encounter by the physician.[42]
[43]
[44] Although insurance payments are increasingly linked to care that is defined as “patient-centered[45],” definitions of this concept vary and effectively do very little to improve the
documentation and addressment of social and emotional elements. Policymakers must
align incentives to promote enhanced documentation that results from the integration
of social and emotional elements into primary care, which will further strengthen
the doctor/patient relationship, a key element of the PCMH and new models of care
such as the Comprehensive Primary Care Plus program.[46]
[47] Future empirical research is needed to define the contributing factors for the lack
of documentation of social/emotional topics relative to other health topics. Our study,
while identifying a gap in documentation of occurring communication, does not attempt
to identify the root cause.
This study has several important limitations. Due to the intensive nature of data
collection and coding, study resources limited the collection of encounters beyond
what was required for the qualitative analysis. Furthermore, our quantitative analysis
was underpowered, resulting in the use of a nonparametric analysis. We include results
from our quantitative analysis to demonstrate that pursuing larger, well-powered studies
on the topic is an important area for future research. Additionally, this study is
an assessment of EHR records and does not compare the documentation of social and
emotional components of care between electronic and paper-based records, which may
have provided an interesting comparative analysis as to whether or not the problem
is resulting from the shift toward electronic documentation.
Conclusion
Treatment recommendations for patients with complex chronic disease must be made in
the context of social and emotional factors. Given the importance of documentation
for interdisciplinary team communication, absence of documentation concerning social
determinants of health can adversely impact patient care. Placing systems, resources,
and tools in the hands of clinicians may make it more feasible for them to disseminate
important office visit communication about social and emotional factors impacting
clinical care through EHR documentation. While many questions exist about how to develop,
structure, and sustain these improvements, such health care investments have great
potential to improve development of personalized care plans for vulnerable patients.
Clinical Relevance Statement
Clinical Relevance Statement
Clinicians routinely discuss social and emotional factors with patients to develop
care plans. Systems' changes that promote feasibility of disseminating these conversations
through EHR documentation can help improve the quality of interdisciplinary communication,
especially during care transitions, such as hospital and specialty care, which are
more often experienced by patients with complex, chronic disease. Innovative and automated
EHR-based solutions, scribe solutions, as well as enhanced reimbursement mechanisms
that make it easier for providers to act on certain social and emotional determinants
of health should be explored and evaluated in research and quality improvement.
Multiple Choice Questions
Multiple Choice Questions
-
Which of the following categories emerging from this study require more thorough documentation
after discussion during an office visit?
Correct Answer: The correct answer is option a. In this study, we found that of 73 total “chronic
conditions” topics, 66 (90.4%) were documented in the encounter's corresponding progress
note. A similarly high percentage of topics were documented in both the “acute/new
problems” and “disease prevention” groups; results showed 16 out of 19 (84.2%) and
8 out of 9 (88.9%) discussions were documented in these categories, respectively.
In contrast, of the 36 “social and emotional health” topics discussed, only 11 (30.6%)
of these details were documented in the corresponding progress note.
-
The results of this study show that physicians are most likely to document the following
type of information after discussing it with the patient:
Correct Answer: The correct answer is option b. The results of our study show that providers were
most likely to document the results of conversations about chronic disease, a topic
for which there was approximately 90.4% agreement between encounter transcripts and
documentation in the EHR. Chronic disease was also the most discussed topic across
all the clinical encounters and the topic discussed for the longest amount of time
(on average) per encounter.
