Study Finds EHRs Can Significantly Improve Clinical Note Quality

November 6, 2014 in News

Electronic health records helped improve the quality of physicians’ clinical notes, according to a study published in the Journal of the American Medical Informatics Association, Clinical Innovation Technology reports.

Study Details

For the study, researchers from the Uniformed Services University of Heath Sciences examined clinical visit notes for 100 patients with Type 2 diabetes. The notes were evaluated six months before and after EHR implementation, and again five years after implementation (Walsh, Clinical Innovation Technology, 11/3).

Notes were scored on a scale from zero to 100 using the QNOTE quantitative tool (Burke et al., JAMIA, 10/23).

Study Findings

Overall, the researchers found that clinical note quality “significantly improved” during the five-year study period (Clinical Innovation Technology, 11/3).

Specifically, the study showed:

  • Clinical notes recorded before EHR implementation scored a 52;
  • Clinical notes recorded six months after implementation scored 61.2; and
  • Clinical notes recorded five years after implementation scored 80.4 (JAMIA, 10/23).

The study found that the largest improvements were made among notes on:

  • Family and social histories;
  • Medical histories;
  • Problem lists; and
  • Review of systems.

Further, the study showed that the core elements that physicians focus on during a patient visit — assessment, chief complaint, history of present illness, physical findings, plan of care and follow-up — improved by 30% (Durben Hirsch, FierceEMR, 10/28).

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