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Group sets ambitious goal: Cut clinical documentation burden by 75% in 5 years

July 1, 2022

Clinical documentation is essential for high-quality patient care, communication among members of the care team, fair and adequate payment, and to satisfy regulatory requirements.

It also is unsustainable and ineffective, according to the AMIA 25x5 initiative.

The initiative was born out of a symposium in early 2021, where a diverse group of health care leaders outlined strategies and priorities to reduce clinicians’ documentation burden to 25% of its current load in the next five years.

“Clinical documentation burden is a pervasive and complex problem that contributes to dissatisfaction and burnout among health care professionals,” said Trent Rosenbloom, M.D., M.P.H., FAAP, symposium co-chair and AMIA 25x5 Task Force member. “It stems from a misalignment between EHR (electronic health record) usability, ever-evolving clinical and regulatory demands, and clinician satisfaction related to entering and using EHR data.”

The American Nursing Informatics Association has identified six areas of documentation that are burdensome: reimbursement, regulatory, quality, usability, interoperability and self-imposed. “When referring to burden as a single entity, we lose the fact that problems with the EHR stem from multiple causes that need attention from varied groups of stakeholders,” the association stated in a position paper (https://bit.ly/3xkIwFH).

Documentation in pediatric care

In pediatrics, there are many patient encounters to document. For example, healthy, typically developing children are supposed to be seen multiple times every year from birth to age 3. A child living with a chronic condition or special health care needs may have even more clinical encounters, including with specialists or in an emergency department.

“Caring for children and their families brings additional documentation requirements that include recording routine health maintenance as children grow, assessment of milestones and routine immunizations, adolescent privacy and consent,” Dr. Rosenbloom said.

Pediatricians also must navigate complexities in terms of who provides information (the patient, a parent/guardian, a state early intervention program, etc.). There may be a wide net of recipients of children’s health information, including schools, child care centers, camps or foster care agencies.

As their patients move from childhood to adolescence to adulthood, pediatricians must deal with a complicated landscape of consent and confidentiality as well as supporting colleagues in adolescent and adult medicine as they take care of their patients and the patients’ records.

Since implementation of the 21st Century Cures Act Interoperability Final Rule in 2021, patients also are much more likely to see pieces of their health record, including encounter notes.

Getting started

Reducing the burden by 75% in the next five years is an ambitious goal.

Individual clinicians did not create documentation burden; it is a systemic concern and challenge. Therefore, all health care stakeholders, including clinicians, health systems, patients, payers, regulators, vendors and advocates, will have to change their behavior and mindset. They will need to work within and across siloes to create, implement and maintain necessary changes.

That being said, pediatricians can take the following actions right away:

  • Think about note bloat. Don’t document what already is in the record.
  • Ask your EHR vendor for resources to track your documentation practices and habits, and implement new strategies.
  • Reach out to the clinical informatician(s) in your health system/clinic and community if you have questions. You also can contact the AAP Council on Clinical Information Technology (COCIT) at https://bit.ly/aapcocit.

“With substantial stresses placed on the health care system over the past few years, we must urgently address documentation burden,” said Dr. Rosenbloom, who is a member of COCIT. “Pediatricians and the AAP are critical contributors and partners as we seek solutions to this ongoing problem.” 

Dr. Chartash is a member of the AMIA 25x5 Task Force and the liaison between the AAP Council on Clinical Information Technology Executive Committee and the Section on Pediatric Trainees.

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