Length and Redundancy of Outpatient Progress Notes Across a Decade at an Academic Medical Center

Adam Rule,Michelle R Hribar,Michael F Chiang,Steven Bedrick

doi:10.1001/jamanetworkopen.2021.15334

Abstract

There is widespread concern that clinical notes have grown longer and less informative over the past decade. Addressing these concerns requires a better understanding of the magnitude, scope, and potential causes of increased note length and redundancy. To measure changes between 2009 and 2018 in the length and redundancy of outpatient progress notes across multiple medical specialties and investigate how these measures associate with author experience and method of note entry. This cross-sectional study was conducted at Oregon Health & Science University, a large academic medical center. Participants included clinicians and staff who wrote outpatient progress notes between 2009 and 2018 for a random sample of 200 000 patients. Statistical analysis was performed from March to August 2020. Use of a comprehensive electronic health record to document patient care. Note length, note redundancy (ie, the proportion of text identical to the patient's last note), and percentage of templated, copied, or directly typed note text. A total of 2 704 800 notes written by 6228 primary authors across 46 specialties were included in this study. Median note length increased 60.1% (99% CI, 46.7%-75.2%) from a median of 401 words (interquartile range [IQR], 225-660 words) in 2009 to 642 words (IQR, 399-1007 words) in 2018. Median note redundancy increased 10.9 percentage points (99% CI, 7.5-14.3 percentage points) from 47.9% in 2009 to 58.8% in 2018. Notes written in 2018 had a mean value of just 29.4% (99% CI, 28.2%-30.7%) directly typed text with the remaining 70.6% of text being templated or copied. Mixed-effect linear models found that notes with higher proportions of templated or copied text were significantly longer and more redundant (eg, in the 2-year model, each 1% increase in the proportion of copied or templated note text was associated with 1.5% [95% CI, 1.5%-1.5%] and 1.6% [95% CI, 1.6%-1.6%] increases in note length, respectively). Residents and fellows also wrote significantly (26.3% [95% CI, 25.8%-26.7%]) longer notes than more senior authors, as did more recent hires (1.8% for each year later [95% CI, 1.3%-2.4%]). In this study, outpatient progress notes grew longer and more redundant over time, potentially limiting their use in patient care. Interventions aimed at reducing outpatient progress note length and redundancy may need to simultaneously address multiple factors such as note template design and training for both new and established clinicians.

Highlights

In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized electronic health record (EHR) adoption in the US at a massive scale.[1]
Mixed-effect linear models found that notes with higher proportions of templated or copied text were significantly longer and more redundant
Interventions aimed at reducing outpatient progress note length and redundancy may need to simultaneously address multiple factors such as note template design and training for both new and established clinicians

Summary

Introduction

In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized electronic health record (EHR) adoption in the US at a massive scale.[1]. Many clinicians spend more time interacting with EHRs than with patients.[7,8,9] Much of that time is spent reading and writing clinical notes, which clinicians claim have grown longer, less informative, and less useful for patient care over time.[10,11,12,13]. Note bloat—the lengthening of notes with repetitive or clinically unhelpful text—has been widely discussed,[10,11,12,13,14,15,16] but there is limited evidence on its scope or causes.[17,18] Epic Systems estimated their clients’ notes doubled in length between 2009 to 2018,18 but no prior work has transparently quantified note bloat at scale. Evidence on causes is lacking, commentaries have pinned note bloat on exacting documentation requirements, such as the Centers for Medicare & Medicaid Services’ (CMS) Evaluation and Management codes, and indiscriminate copying of note text.[10,11,12,13,18,19,20,21] Perceived consequences include notes taking longer to write, being more difficult to review, and being less accurate sources of data for quality improvement and research,[13] these outcomes are difficult to measure quantitatively

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Conclusion