The importance of complete and accurate clinical documentation is unquestionable. Patient health records provide insight into patients’ past medical histories and the care and services they receive. They also serve as the basis for billing, and hold legal bearing for the patient, the provider, and the healthcare organization. Over the years, the care provided to patients has become increasingly complex and with that, has come increased demands in clinical documentation. Many nurses have described the amount of documentation required as burdensome, both physically and cognitively. Many interventions aimed at improving clinical documentation workflows have been attempted, with some success; however, current documentation practices remain a leading issue identified by nurses (Padden, 2019).
The Rise of the Electronic Health Record
Today, nearly all healthcare organizations have moved away from paper charting and have adopted and implemented an electronic health record (EHR) system. This transition has provided countless benefits to patients and clinicians. Unfathomable amounts of healthcare data are collected, organized, and stored daily. These systems have largely decreased issues related to transcription and allow users to quickly find and retrieve desired data and track trends in real time (Sewell, 2019). Despite their benefits, EHR systems are not without issue. There are many EHR systems on the market and capabilities vary widely. Furthermore, these systems are often customized based on the purchasing organizations’ preferences, widening variability even more. As a result, many of these systems are incapable of interacting with one another. This has resulted in fragmentation of patient health data, which contributes to the issue of redundant documentation.
A Personal Experience
Take a moment and imagine you are sick. Sick enough that you decide your ailment warrants a trip to the local emergency department. When you walk in you are greeted by the registration clerk who asks you a number of questions regarding demographics, billing information, and your reason for visit. After some time, you then meet with the triage nurse who again asks several questions related to your medical history and current ailment. The ED physician then pops in and asks you many of the same questions. Based on your workup, it is decided that you will require admission to an inpatient unit. After being wheeled into your room the hospitalist comes in to evaluate you. He again questions you regarding past medical history and your current ailment. As he leaves, the primary nurse enters the room. She informs you that she is going to complete your admission and needs to ask you some questions concerning your past medical history and current ailment.
Notice the redundancy? Unfortunately, this often represents the patient’s experience. At one hospital, which I was previously employed, the emergency department and inpatient units used different charting systems. Surprisingly enough, there was virtually no crossover of information between the two platforms. Another system was used for billing, which, again, did not communicate with the other systems. This required patient charges to be reviewed and manually entered. In the intensive care unit, where I worked, the monitors were not set up to interact with the EHR system. This forced nurses to manually enter vital signs as often as every 5 to 15 minutes in especially unstable patients. Furthermore, the inpatient EHR system utilized countless static forms, which had significant overlap in required information and the admission process was complex and cumbersome.
Issues Associated with Redundancy in Clinical Documentation
From the example provided, one can easily identify several potential consequences associated with redundant clinical documentation. When a patient visits the hospital, they are often experiencing a wide range of emotions, such as stress and anxiety. The associated tensity is further compounded by the fact that they feel unwell physically. As a result, having to answer the same questions again and again can lead to feelings of frustration and even negative perceptions of care. From a nursing standpoint, the workload seems to grow continually, and time is essential. Requiring double documentation of patient information and manual entry of troves of clinical data pulls nurses away from the bedside and creates competing priorities, which could potentially affect the quality of patient care. Additionally, the reentry of data by multiple providers increases the risk of inaccuracies and discrepancies in information, which could pose clinical and legal ramifications.
Potential Solutions to Redundancies in Clinical Documentation
- Retire antiquated technologies and practices
- Shift focus to multi-disciplinary documentation
- Increase interoperability
Retire antiquated technologies and practices
Technology in healthcare is continually evolving and EHR systems continue to implement new improvements and functionalities to overcome identified challenges. Legacy systems that fail to address known issues should be abandoned in favor of systems that support clinicians. Nurses must also speak up when concerns emerge regarding the efficiency of established practices and processes. As the adage goes, “just because you’ve always done it that way don’t mean it’s the right (or best) way.”
Shift Focus to Multi-disciplinary Documentation
Healthcare today employs a multi-disciplinary approach to patient care. Among disciplines, there is significant overlap in documentation. Therefore, all data should be visible and available to all users. Additionally, functionalities, such as autofill, should be utilized for information that is unlikely to change (Wroten et al., 2020). Unfortunately, some EHR systems, like the one discussed in the example, continue to create silos of documentation. In the provided example the patient’s medical information was individually re-entered three to four times in one encounter. In a 2014 study, researchers found that redundant work accounted for 22% of the time necessary to complete admission and discharge documentation (MacMillan et al., 2014). Therefore, eliminating duplication by making one party responsible for obtaining and documenting necessary history would have a significant impact on efficiency.
Increase interoperability
Interoperability refers to the compatibility of multiple systems. Systems are said to be interoperable when they are able to “communicate” and transfer data from one system to another in a meaningful way (Sewell, 2019). Looking back at the provided example, the described facility had failed to achieve interoperability between in-house systems. This resulted in multiple instances of duplicate documentation, decreased efficiency, and increased documentation burden on clinical staff. Facility-level interoperability would have had a significant, positive effect on clinical workflows. Due to many factors, large scale interoperability has not yet been achieved. Recent legislation, known as the Cures Act Final Rule, aims to move us closer to national interoperability by standardizing data sets used by EHR systems (Anthony, 2020). Despite the progress, interoperability remains a pressing topic in nursing informatics today.
Benefits of Reducing Redundancy in Clinical Documentation
- Benefits to the Healthcare Team – Decreased documentation, increased efficiency, and more time to provide care at the bedside.
- Benefits to the Patient – Decreased wait times and improved patient perceptions and satisfaction.
- Other Potential Benefits – Minimize duplicate data and decrease risk of documentation error and information discrepancies.
Final Thoughts
Redundancy in clinical documentation is just one challenge faced by healthcare workers today. Progress in addressing this issue has been made through improvements in EHR system functionalities and the introduction of legislation that encourages national interoperability; however, this issue will require continued research and intervention. Reduction of redundancy in clinical documentation stands to provide significant benefit to both patients and healthcare providers.
References
Anthony, S. (2020). The Cures Act Final Rule: Interoperability-focused policies that empower patients and support providers. Retrieved from https://www.healthit.gov/buzz-blog/21st-century-cures-act/the-cures-final-rule
MacMillan, T., Slessarev, M., & Etchells, E. (2014). eWasted time: Redundant work during hospital admission and discharge. Health Informatics Journal, 22(1), 60-66. https://doi.org/10.1177/1460458214534091
Padden, J. (2019). Documentation burden and cognitive burden: How much is too much information?. CIN: Computers, Informatics, Nursing, 37(2), 60-61. Retrieved from https://www.nursingcenter.com/journalarticle?Article_ID=4907841&Journal_ID=54020&Issue_ID=4907806
Sewell, J. (2019). Informatics and nursing: Opportunities and challenges (6th ed.). Philadelphia, PA: Wolters Kluwer.
Wroten, C., Zapf, S., & Hudgins, E. (2020). Effectiveness of electronic documentation: A case report. The Open Journal of Occupational Therapy, 8(3), 1-10. https://doi.org/10.15453/2168-6408.1722
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