Restoring Meaningful Content to the Medical Record: Standardizing Measurement Could Improve EHR Utility While Decreasing Burden

Abstract

Electronic health records (EHRs) dominate clinicians’ time.1 This time on the computer is often not well spent: EHRs are known for their poor usability and clerical burden, producing “bloated” notes with patient narratives and clinical reasoning lost in a sea of extraneous data and text.2 Yet the EHR’s exact purpose in clinical practice and documentation remains conflicted, with billing and clerical roles often eclipsing communication and decision-making capabilities. When fully realized, the EHR has the potential to be a valuable resource that assists with several tasks: documenting patient narratives, physical findings, and test results; using patient-specific data, medical knowledge, and computational power to support sound medical decision-making; documenting the resultant care plans and the reasoning and assessments behind them; facilitating order entry and communication with patients and other clinicians; and efficiently organizing large-volume data to enhance research and population health tracking.