In 2021, a group of informaticists and other stakeholders led an ambitious call to action for health systems and health IT vendors to reduce clinical documentation burden in EHRs to 25 percent of its current level by 2025. Now, an American Medical Informatics Association (AMIA) 25x5 Task Force has developed a Toolkit to guide organizations through the process of reducing documentation burden.
The Toolkit is intended to provide resources related to governance of EHR optimization, implementation of solutions to reduce burden, and measurement of burden reduction.
The Toolkit begins by noting that recent studies have shown that clinicians spend a significant amount of time documenting. As a result, there are increased errors, unintended consequences, and less time to have meaningful interactions with patients, their caregivers, and families. Further, research links documentation burden to job dissatisfaction, stress, and clinician burnout, so reducing documentation burden may result in improvements to clinician well-being, safety, quality, and patient experience.
The authors notes that no single solution to addressing documentation burden will fit all organizations. The Toolkit is intended to provide comprehensive guidance to individuals and organizations for a pragmatic approach to documentation burden reduction.
One key to these efforts is effective governance, which ensures appropriate organization, resource allocation, and coordination of efforts to achieve goals and ensure quality, safety, and fiscal stewardship. “Without a governance structure to form an organized framework to address documentation requirements and efficiency, the process of identifying and implementing opportunities for optimization can evolve into disarray,” the authors note. “A single stakeholder’s voice may be disproportionately represented, leading to an imbalance in goals or priorities. These factors may contribute to duplication, inefficiency, and dissipation of effort.”
The Toolkit mentions shared governance and steering committees as examples of governance approaches to consider.
One set of guiding principles could include the extent to which documentation supports:
- Efficient clinical care
- Existing vs best E&M billing guidance
- Patient safety & quality
- Compliance standards (local, national)
- Minimizing or eliminating documentation duplication
- Clinician and/or team well-being
- Team-based care
In order to inventory existing documentation burden reduction activities, the AMIA 25x5 Task Force performed a literature search and distributed a national survey, from August 10, 2022 to September 9, 2022, requesting health organizations describe how they have approached reducing clinician documentation burden. The literature search identified more than 30 organizations that had published on their initiatives.
Eighteen organizations responded to the 2022 survey and submitted details on initiatives being implemented or completed. The Toolkit summarizes and provides further details on those efforts.
Generally speaking, the Physician/APP initiatives focus on reducing note bloat and the Nurse initiatives focus on reducing flowsheet documentation.
The Task Force received 12 provider responses focusing on using standardized note templates to reduce duplication and length while assuring that reimbursement requirements were met. Many organizations used the 2021 ambulatory E&M changes as an opportunity to streamline documentation requirements. The Task Force received seven responses focused on reducing and streamlining admission nursing documentation.
Some initiatives focused on reducing documentation quantity, while others addressed the process of documenting. “While interventions with scribes or ambient voice recognition to reduce time spent documenting are laudable, we believe documentation burden derives not only from time spent documenting, but also the cognitive burden and time spent formulating ideas that become the documentation, including chart review, documenting, and reviewing past documentation,” the authors wrote. “Efforts to reduce time spent documenting must be paired with efforts to reduce the total quantity of documentation, as well.”
The Toolkit also notes that it is important to establish goals for the interventions and how the efforts will be assessed.
Measuring documentation “burden” may take the form of simple, EHR-derived time measures to complex algorithms to assess the experience of the user, as is evaluated with measures of burnout. Organizations may want to establish plans that evolve from measuring documentation duration/length to one that measures burden of the experience. It is important to remember the goal is to reduce total documentation burden, not only reduce the time it takes to document or the time spent by one member of the team. No matter the measures, the Task Force notes, it will be important to assess them before, during, and sometime after the intervention to allow the organization to determine the effect and sustainability of the designed intervention.
In its conclusion, the Task Force notes that EHR vendors play a role in minimizing the burden of information retrieval and synthesis, eliminating duplicate documentation, complying with regulatory requirements in a non-interruptive manner, and supporting team-based care and documentation. “To this end, the AMIA 25x5 Task Force continues to address each of these arms individually and together as part of the larger goal to reduce documentation burden. Next steps include building an online learning community that provides a forum and opportunity to share documentation burden reduction initiatives and their implementation.”