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IJB-3145; No.

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journal homepage: www.ijmijournal.com

Review

Medical documentation: Part of the solution, or


part of the problem? A narrative review of the
literature on the time spent on and value of
medical documentation

Neil Clynch a , John Kellett b,∗


a Dundalk Institute of Technology, Dundalk, Ireland
b Thunder Bay Regional Health Sciences Center, Thunder Bay, ON, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: Even though it takes up such a large part of all clinicians’ working day the
Received in revised form medical literature on documentation and its value is sparse.
23 November 2014 Methods: Medline searches combining the terms medical records, documentation, time, and
Accepted 5 December 2014 value or efficacy or benefit yielded only 147 articles. This review is based on the relevant arti-
cles selected from this search and additional studies gathered from the personal experience
Keywords: of the authors and their colleagues.
Medical records Results: Documentation now occupies a quarter to half of doctors’ time yet much of the
Medical documentation information collected is of dubious or unproven value. Most medical records departments
Electronic medical records still use the traditional paper chart, and there is considerable debate on the benefits of
Quality of care electronic medical records (EMRs). Although EMRs contains a lot more information than a
paper record clinicians do not find it easy to getting useful information out of them. Unlike
the paper chart narrative is difficult to enter into most EMRs so that they do not adequately
communicate the patient’s “story” to clinicians. Recent innovations have the potential to
address these issues.
Conclusion: Although documentation is widespread throughout the health care industry
there has been almost no formal research into its value, on how to enhance its value, or
on whether the time spent on it has negative effects on patient care.
© 2014 Elsevier Ireland Ltd. All rights reserved.


Corresponding author at: Hospitalist Service, Thunder Bay Regional Health Sciences Center, 980 Oliver Road, Thunder Bay, ON P78 7A5,
Canada. Tel.: +1 807 684 6030; fax: +1 807 684 5894.
E-mail address: jgkellett@eircom.net (J. Kellett).
http://dx.doi.org/10.1016/j.ijmedinf.2014.12.001
1386-5056/© 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: N. Clynch, J. Kellett, Medical documentation: Part of the solution, or part of the prob-
lem? A narrative review of the literature on the time spent on and value of medical documentation, Int. J. Med. Inform. (2014),
http://dx.doi.org/10.1016/j.ijmedinf.2014.12.001
IJB-3145; No. of Pages 8
ARTICLE IN PRESS
2 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s x x x ( 2 0 1 4 ) xxx–xxx

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Information overload – getting less out of more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Will computers help? Pros and cons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. The EMR of the future – can they get more out of less? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Point-of-care documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Author contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

of care has become more important than its actual delivery


1. Introduction [16]. Much of this documentation has been mandated by the
common but mistaken assumption that complex systems like
In 1964 Dr Laurence Weed published his first article on the health care can be made safer by adding more complexity [17].
problem oriented medical record in the Irish Journal of Med- Although originally introduced to help the clinicians’ mem-
ical Science [1]. At that time a consultation in hospital from ory and organize their thought processes, the medical record
a medical specialist consisted of a detailed history that may now may often be more of a hindrance than a help to patient
have taken up to 20 min, followed by a comprehensive physical care. Even though it takes up such a large part of all clinicians’
examination that usually took another 10 min. The junior doc- working day the medical literature on documentation and its
tor would then be asked if there were any abnormalities in the value is sparse. Medline searches on May 7th 2014 combining
urine, and if he had looked at the blood smear. A chest X-ray the terms medical records, documentation, time, and value or
may have been available for review, and there may have been a efficacy or benefit yielded only 147 articles, most which were
brief discussion on what an ECG tracing may or may not reveal, commentaries and editorials. This review is based on 43 rele-
and if it were worth doing. The consultant would then write vant articles selected from this search and additional studies
the patient’s diagnosis in the chart and prescribe treatment. gathered from our personal experience and that of our col-
Over 90% of the total time spent on the consultation was at the leagues – of these only 38 papers were peer reviewed original
patient’s bedside. Compare this to a modern day consultation research (Table 1).
during which little time is spent with the patient [2–4], and
most spent trawling through the patients chart, determining
what investigations and treatments have already been done, 2. Information overload – getting less out of
what other physicians thought, what numerous paramedical more
assessments suggested, what medication the patient is on,
has been on, and can or cannot take etc. Traditionally only one doctor was the primary author of the
Over the years the amount of documentation routinely medical record. As medical care has become more complex
recorded at every medical encounter has grown exponentially and fragmented medical records now have multiple contrib-
so that it now occupies a quarter [2,4] to half [5] of doctors’ utors, so the record has become organized into different
time. At the Hospital for Sick Children’s intensive care unit in sections that each of the multiple users of the chart can
Toronto documentation increased by 25% from 1999 to 2005 quickly find. For doctors there is the admission note, the
by which time 1348 items of information were documented history and physical, progress notes, doctors’ orders and con-
on each patient every 24 h [6]. In the United Kingdom [7] and sultations. Nurses in particular are now required to complete
Australia [8] nurses spend approximately 20% of their time a considerable amount of documentation on every patient
on documentation and in the United States every hour of admitted to hospital, which may be further sub-divided into
patient care now requires from 30 min to 60 min of paper- special sections addressing issues like bedsores, nutrition,
work [7,9,10]. Even the most trivial clinical episode, which a bowels, sleep, emotional state etc. (Fig. 1). The social worker’s
generation ago would have warranted only a brief note scrib- section records socio-economic issues such housing, accom-
bled on a small card, now requires several pages of forms modation, family dynamics, religious and cultural difficulties,
containing voluminous information of dubious or unproven as well financial and employment related problems. Then
value [11–14]. Collection of this data is time consuming and, there are the vital signs, laboratory and diagnostic imaging
therefore, detracts from patient care. Time spent analyzing results, lists of allergies and the current medications that also
and completing documentation reduces the amount of qual- include a record of when and by whom they were given and
ity time that a physician has to care for their patient and their if they were taken. Finally there is a section for miscellaneous
relatives, not to mention teaching and clinical research [15]. information that might contain multiple correspondence, do
Whilst there is an obvious need for medical documentation its not resuscitate orders, letters of complaint, legal letters etc.
recent increase has been driven by administrators and their Multiple symptoms and signs, hypotheses, problems, possible
legal advisors without any evidence that it improves medi- diagnoses, concerns, doubts, musings, opinions, suggestions,
cal care, and a culture is developing in which documentation observations, progress notes, discussions and assessments

Please cite this article in press as: N. Clynch, J. Kellett, Medical documentation: Part of the solution, or part of the prob-
lem? A narrative review of the literature on the time spent on and value of medical documentation, Int. J. Med. Inform. (2014),
http://dx.doi.org/10.1016/j.ijmedinf.2014.12.001
IJB-3145; No. of Pages 8
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i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s x x x ( 2 0 1 4 ) xxx–xxx 3

Table 1 – References cited according to type.


Paper type References Number
Opinion/Commentary/ [1,14,22,27,28,51,63,73,74,81,82,83] 12
Editorial/Proposal
Peer reviewed original [2,3,4,5,6,8,10,11,18,19,21,26,29,30,31,34,37,39,40,41,42,43,44,45,46,48,49,52,53,58,62,67,71,75,76,77,79,80] 38
research
Reviews [12,13,16,32,33,35,36,38,50,55,56,70,72] 13
Reports [9,15,20,23,24,25,78] 7
Software descrip- [47,54,57,59,66] 5
tion/evaluation
Methodology [68] 1
Book [17,60,61,69] 4
Personal [7] 1
communication
Research letter [64,65] 2

Fig. 1 – Filing cabinet containing the nursing assessment forms routinely filled out in a major Dublin teaching hospital.

are recorded. Some of this data is factual and some is opinion, the time and effort that goes into documentation, important
some speculative, some assumed, some contradictory, not all pieces of information are often difficult to obtain: the pre-
is accurate and some just plain wrong. Much of this data is senting complaint and precise need for hospital admission, an
often reiterated multiple times by multiple authors of uncer- accurate summary of co-morbid conditions and their sever-
tain identity in different sections of the chart, and like the ity prior to the current illness, the patient’s mental status
game of Chinese Whispers may vary slightly, or even com- and functional capacity, an estimate of illness severity and
pletely, from iteration to iteration. immediate risk of death, the long-term life expectancy and
Not surprisingly the response to this “information over- the patient’s wishes for resuscitation and end-of-life care [19].
load” has been for most users to only consult the part of
the chart that they are familiar with and for which they feel
responsible – few users will ever wander outside these con- 3. Will computers help? Pros and cons
fines. As a result documentation from these different silos is
seldom shared between clinicians and, even though it may
Paper charts have obvious limitations such as fragmentation
contain important information, it is seldom used to prospec-
of patient data, missing records and poor legibility that can
tively drive or assist patient management. Only about 38% of
be partly addressed by an electronic medical record (EMR)
all healthcare providers’ notes, and only about 20% of nurses’
system. However, despite the widespread use of computer
notes are ever read by anyone else [18]. Furthermore, despite
technology in other industries many medical records still use

Please cite this article in press as: N. Clynch, J. Kellett, Medical documentation: Part of the solution, or part of the prob-
lem? A narrative review of the literature on the time spent on and value of medical documentation, Int. J. Med. Inform. (2014),
http://dx.doi.org/10.1016/j.ijmedinf.2014.12.001
IJB-3145; No. of Pages 8
ARTICLE IN PRESS
4 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s x x x ( 2 0 1 4 ) xxx–xxx

the traditional paper chart [20]. In 2009 only 1.5% of U.S. hos- examination. The collection and recording this narrative
pitals had a comprehensive electronic-records (EMR) system should be easy and meet the specific needs of clinicians in
(i.e., present in all clinical units), although 7.6% did have a basic their daily practice without creating extra work [55,63]. How-
system (i.e., present in at least one clinical unit) [21]. As a result ever, unlike the paper chart it is difficult to enter narrative into
of the HITECH Act [22] the adoption of computer systems has EMRs, which usually use menus and “check boxes” that do not
increased dramatically in the last few years, so that as of 2013 adequately communicate the patient’s “story” to the reader,
78.4% of physicians’ offices [23] and 57.4% of hospitals [24] and may generate so many flags, messages and alarms that
now have a basic EMR system. There are few other industries they cease to be informative and become noise [64,65].
that have been asked adopt so quickly such a highly regulated One of the consequences of EMR use has been a reduc-
form of technology, which, as yet, has not been shown to be of tion in face-to-face communication between clinicians and
proven benefit. A recent RAND survey [25] found that EMR use patients [25] and between clinicians themselves, so that every-
to be a major determinant of physician job satisfaction. Wor- one caring for the patient now has to spend more time double-
ryingly, 10% of physicians still prefer paper records, and that and triple-checking to make sure they understand what the
EMR usability, or lack of it, was a major concern. Important exact goals of treatment are [66]. In order to save data entry
complaints were that different EMRs often did not communi- time many users “copy-and-paste” previous entries, with the
cate with each other [26], often reduced practice efficiency [27] result that errors are perpetuated and, hence, the entire record
and increased costs [28], did not consistently prevent errors tends to be doubted [67]. The other consequence of “copy-
[29], sometimes introduced errors [30,31], and seldom pro- and-paste” is that it greatly increases the size of the chart,
vided sufficient or appropriate automatic electronic alerts [27]. thus, creating further “information overload” to the reader
Meaningful use of computer technology, such as e-prescribing [62]. Therefore, at the present time, even though an EMR con-
or using information to both report on and improve the quality tains a lot more information than a paper record and should
of care quality, is a cornerstone of the HITECH Act. However, be easily searched, clinicians do not find it easy to get useful
many physicians reported a mismatch between these crite- information out of them.
ria and what they considered the most important elements
of patient care [27]. Many of these “teething problems” did
not improve with time and, surprisingly, the greater the EMR’s 4. The EMR of the future – can they get
functionality the more physician job satisfaction was reduced more out of less?
[25].
Currently there is considerable debate [32,33] over whether Although physicians may think that performing a history
entering data into an EMR takes less [34–39] or even more and physical, ordering investigations, making a diagnosis and
time than paper documentation [40–47]. Nevertheless EMRs devising a treatment plan are separate processes, in reality
have the potential benefits of being able to ensure uniformity they are all interconnected and each is driven and modulated
of data, easier reporting of data (e.g. by a standard letter to by each of the others. Even the most experienced clinicians
the general practitioner), and more advanced decision sup- find organizing and planning these processes efficiently diffi-
port (e.g. by embedding clinical guidelines in the EMR), quality cult, especially if the patient has multiple complex conditions
assessment, and patient-oriented clinical research. Fifteen or that are unstable and changing rapidly.
more years ago it was thought that all these benefits would As more and more information is gathered on a patient by
result in better and more complete documentation of patient different care-givers the true nature of the patient’s predica-
data and more efficient and better patient care [48–53]. How- ment should become clearer. However, this is often not the
ever, many of these aspirations have remained unfulfilled, case. For example, a patient presenting with breathlessness
as in order to achieve them structured data entry is required may be correctly diagnosed as suffering from chronic obstruc-
(i.e. entry of predefined medical concepts, usually achieved by tive pulmonary disease. In addition the patient’s nurse may
way of a template style graphical user interface). Although the discover she is also suffering from memory loss and mild
importance of structured data entry is acknowledged in exist- dementia. Collateral history, obtained by social services may
ing electronic medical record systems [49,54], it is clumsy to reveal that the patient’s son, her only carer, has recently devel-
use and results in caregivers spending much of their time on oped cancer and has been finding it more difficult to look
tedious and repetitive entry of data into checkboxes. Introduc- after her, especially as she has been getting more agitated
ing it into a broad specialty such as internal medicine has and confused at night. As a result, he confides to his mother’s
proven to be a significant challenge [48,55,56] and so far its physiotherapist, he has been giving her some of his pain med-
use has been mostly limited to areas such as radiology or ication to help her sleep. Although all this information would
endoscopy [57–59]. likely be recorded in different sections or silos of the tradi-
Capturing the patient’s history by narrative is highly val- tional medical record, it would not be available to prompt the
ued by clinicians as it links information between low and physician to consider that the patient’s immediate problem
high-level clinical objectives [60], thus improving situational might be opiate intoxication, and that the root cause of this is
awareness [61] and collaboration between colleagues [62]. the care giver’s increasing inability to cope. If a specific med-
However, medical narrative data are diverse, and vary by ical notation or language [68] existed it should be possible to
discipline, by patient, and over time. Internal medicine, in design an electronic medical record that would identify all
particular, requires the recording of a wide range of narra- these issues and present them to the clinician as the record is
tive varying from straightforward to very complex problems constantly updated by different contributors. Although there
covering all aspects of both patient history and physical are several medical terminologies in use (e.g. ICD-10, DRGs,

Please cite this article in press as: N. Clynch, J. Kellett, Medical documentation: Part of the solution, or part of the prob-
lem? A narrative review of the literature on the time spent on and value of medical documentation, Int. J. Med. Inform. (2014),
http://dx.doi.org/10.1016/j.ijmedinf.2014.12.001
IJB-3145; No. of Pages 8
ARTICLE IN PRESS
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s x x x ( 2 0 1 4 ) xxx–xxx 5

Read Codes, SNOMED etc.) medicine is remarkable for its fail- information should be collected frequently and then tracked
ure to develop a standardized vocabulary and nomenclature. and charted. Significant changes in the patient’s condition
Other disciplines have developed precise terminology or nota- should then automatically trigger clinical interventions that
tion that is standardized and accepted by all workers in the have been shown by clinical research to benefit the patient.
field [69]. Musical notation, for example, is a domain specific The introduction of National Early Warning Scores into the
language, that allows precise representation, and hence faith- UK and Ireland is the first step in this process [78]. Although
ful reproduction of music exactly as the composer intended. the score is calculated in most hospitals by pencil and paper,
Such succinctness and accuracy is not possible in medicine, a this would be performed more accurately by a computer [79],
discipline in which it is hard to find two people that agree and if entered electronically at the bedside immediately avail-
completely on anything and which still only uses natural able to everyone looking after the patient. This approach has
language. Use of a medical domain-specific language would recently been shown to reduce in-hospital mortality [80]. The
allow the computer to recognize important medical issues next step is to develop better methods for collecting informa-
as they appeared in a medical record without the need for tion, manipulating it using validated clinical models and then
structured data entry. Since the entire record would now presenting it in format that will allow clinicians to immedi-
be machine-readable the computer could then organize and ately grasp the patient’s story and clinical predicament. This
manipulate these issues to make immediate clinically rele- may include automated systems for collecting vital signs and
vant unprompted suggestions. Furthermore, it would make other clinical data, and then generating appropriate alarms
it easier to get the computer to look for things and perform to clinical staff with as few false alarms as possible. In short,
certain tasks, such as discharge summaries, laboratory req- it must be quick and easy to enter data into EMRs [19], and
uisitions etc. However, even advanced cognitive computers, EMRs must be able to automatically pull relevant clinical data
such as IBMs supercomputer Watson [70], which do not require from the chart, both before and during hospitalization, and
machine readable information, have yet to be shown to be able manipulate it so that the patient’s “story” and current predica-
to accurately identify appropriate medical chart information, ment are presented at a glance [81]. Furthermore, prior to their
reconcile conflicting elements, and then generate coherent adoption clinical trials should show that novel documentation
recommendations of clinical value. Whilst the development systems, like any other medical intervention, improve clinical
and widespread adoption of a medical domain specific lan- outcomes.
guage may seem fanciful, some effort should at least be made
to establish those clinical observations with acceptable inter-
observer agreement (i.e. a kappa score in excess of 0.6) [71,72] 6. Conclusion
and, therefore, since they mean the same thing to most clini-
cians, are valuable and well worth recording. In contrast there Although documentation is widespread throughout the health
seems little point in continuing to store clinical information care industry there has been almost no formal research into
with low inter-observer agreement that is, therefore, at best its value, on how to enhance its value, or on whether the
valueless and at worst misleading. time spent on it has negative effects on patient care. Instead
physicians have passively allowed administrators and regula-
tors to impose ever increasing documentation on them and
5. Point-of-care documentation shown little interest in studying its potential benefits for and
threats to patient care. It is almost 45 years since Dr Weed
The introduction of the tablet computer now makes it possible proposed numerous ways computers could change the way
for patient information to be entered promptly at the bedside medical information was collected, recorded and used [82].
and then immediately disseminated via the EMR to everyone Little of what he suggested has been implemented. Currently
responsible for the patient’s welfare [73]. This means that any most EMR systems have done little more than replace the doc-
change in the patient’s condition should be quickly recognized tor’s medical record cabinet and prescription pad [83]. The
and appropriately managed. Technology alone, however, will journey to make documentation pro-actively drive care so that
not lead to “a world of real-time information.” [42]: for this it directly benefits patients has yet to begin.
to take place nursing documentation culture must change.
Nurses will have to lose their discomfort charting patients’
private details at the bedside [74] and their attachment to
Author contributions
informal and temporary paper notes and “batch” charting,
whereby patient data is accumulated throughout the day and
Both authors contributed to this paper by performing repeated
only entered later into the computer [75]. The way patients
literature and internet searches as well as prolonged dis-
are assessed at the bedside will also have to be standard-
cussions and debates with their medical and information
ized and use common data elements [76]. The questions asked
technology colleagues.
should be tailored to each individual patient and their clinical
predicament, so that the maximum amount of accurate and
reliable information is gained from the smallest number of
questions [77] that have minimal inter-observer disagreement Conflict of interest
[71,72]. Patient information that is stable over time should
be collected once, carefully validated and then used often This paper received no funding from any third party and nei-
to appropriately guide each subsequent assessment. Volatile ther of the authors has any conflict of interest.

Please cite this article in press as: N. Clynch, J. Kellett, Medical documentation: Part of the solution, or part of the prob-
lem? A narrative review of the literature on the time spent on and value of medical documentation, Int. J. Med. Inform. (2014),
http://dx.doi.org/10.1016/j.ijmedinf.2014.12.001
IJB-3145; No. of Pages 8
ARTICLE IN PRESS
6 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s x x x ( 2 0 1 4 ) xxx–xxx

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lem? A narrative review of the literature on the time spent on and value of medical documentation, Int. J. Med. Inform. (2014),
http://dx.doi.org/10.1016/j.ijmedinf.2014.12.001

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