Now that EHR adoption is up, it's time to overhaul clinic notes

Most physicians are dissatisfied with the "review of systems" section of their EHR, which is the part required by Medicare and Medicaid for billing purposes, according to a study from the Journal of the American Board of Family Medicine.

Physicians who took part in the study reported overwhelming satisfaction with the "assessment" and "plan" sections of clinic notes. These were rated the most important in terms of containing information valuable to patient care and oftentimes users would skip over the "review of systems" section to get to them first.

"Most physicians we observed skipped right to the assessment and plan sections, which include the diagnoses of the patient from the last visit and notes on how physicians planned to address the diagnoses," Richelle Koopman, MD, associate professor of family and community medicine at the MU School of Medicine and co-author of the paper, said in a statement. "In addition, physicians expressed a lot of frustration about the poor utility of the 'review of systems' section and said it had little value in addressing patient care."

While EHRs enable physicians to access more patient information than they ever have before the HITECH Act and ubiquitous adoption of the platform, they view much of the information as extraneous and not crucial to patient care, according to Dr. Koopman.

The results support the need to change the information that is necessary for medical billing and to find a more streamlined method of presenting medical information that will both reduce errors and improve outcomes, the authors concluded.

Further research will focus on identifying the most efficient way to organize patient data in the clinic notes portion of an EHR using eye-tracking software, to see how quickly physicians are able to find the information they are looking for in a laboratory setting using different clinic notes prototypes.

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