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. Note bloat-the lengthening of notes with repetitive or clinically unhelpful text-has been widely discussed, 10 - 16 but there is limited evidence on its scope or causes. 7 - 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. Many clinicians spend more time interacting with EHRs than with patients. 2 - 6 However, EHR adoption has also been accompanied by sweeping regulatory change and growing concern that clinicians spend too much time documenting. 1 The ensuing migration from paper to digital records transformed US health care, improving medication safety and guideline adherence while providing a wealth of data for quality improvement and research. 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.
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. Residents and fellows also wrote significantly (26.3% ) longer notes than more senior authors, as did more recent hires (1.8% for each year later ).Ĭonclusions and Relevance In this study, outpatient progress notes grew longer and more redundant over time, potentially limiting their use in patient care. 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% and 1.6% increases in note length, respectively). 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. 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. Results A total of 2 704 800 notes written by 6228 primary authors across 46 specialties were included in this study. Main Outcomes and Measures 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. Statistical analysis was performed from March to August 2020.Įxposures Use of a comprehensive electronic health record to document patient care.
Participants included clinicians and staff who wrote outpatient progress notes between 20 for a random sample of 200 000 patients. Objective To measure changes between 20 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.ĭesign, Setting, and Participants This cross-sectional study was conducted at Oregon Health & Science University, a large academic medical center. Addressing these concerns requires a better understanding of the magnitude, scope, and potential causes of increased note length and redundancy. Importance There is widespread concern that clinical notes have grown longer and less informative over the past decade. Shared Decision Making and Communication.Scientific Discovery and the Future of Medicine.Health Care Economics, Insurance, Payment.Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography.