EHRs can improve clinical note quality
Physicians' clinical notes improved in quality after EHR implementation, according to an article published in the Journal of the American Medical Informatics Association (JAMIA).
Researchers from the Uniformed Services University of the Health Sciences in Maryland conducted a five-year multicenter study of the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with Type 2 diabetes. The notes were evaluated six months before EHR implementation, six months after implementation and five years after implementation, using an instrument called QNOTE.
Note quality "significantly improved" over five years but some improved in just the first six months after EHR implementation. The largest improvements were in problem lists, past medical history, social and family history and review of systems. There was a 30 percent improvement in core note quality, consisting of chief complaint, HPI, physical findings, assessment, plan of care and follow-up.
The researchers noted there currently is no standard to assess note quality so there is no feasible way to provide physicians with feedback to improve their clinical notes.
Access the complete study.
Editor
Editor Beth earned a bachelor’s degree in journalism and master’s in health communication. She has worked in hospital, academic and publishing settings over the past 20 years. Beth joined TriMed in 2005, as editor of CMIO and Clinical Innovation + Technology. When not covering all things related to health IT, she spends time with her husband and three children.