Toward Alleviating Clinician Documentation Burden: A Scoping Review of Burden Reduction Efforts

Abstract

Background Studies have shown that documentation burden experienced by clinicians may lead to less direct patient care, increased errors, and job dissatisfaction. Implementing effective strategies within health care systems to mitigate documentation burden can result in improved clinician satisfaction and more time spent with patients. However, there is a gap in the literature regarding evidence-based interventions to reduce documentation burden.

Objectives The objective of this review was to identify and comprehensively summarize the state of the science related to documentation burden reduction efforts.

Methods Following Joanna Briggs Institute Manual for Evidence Synthesis and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, we conducted a comprehensive search of multiple databases, including PubMed, Medline, Embase, CINAHL Complete, Scopus, and Web of Science. Additionally, we searched gray literature and used Google Scholar to ensure a thorough review. Two reviewers independently screened titles and abstracts, followed by full-text review, with a third reviewer resolving any discrepancies. Data extraction was performed and a table of evidence was created.

Results A total of 34 articles were included in the review, published between 2016 and 2022, with a majority focusing on the United States. The efforts described can be categorized into medical scribes, workflow improvements, educational interventions, user-driven approaches, technology-based solutions, combination approaches, and other strategies. The outcomes of these efforts often resulted in improvements in documentation time, workflow efficiency, provider satisfaction, and patient interactions.

Conclusion This scoping review provides a comprehensive summary of health system documentation burden reduction efforts. The positive outcomes reported in the literature emphasize the potential effectiveness of these efforts. However, more research is needed to identify universally applicable best practices, and considerations should be given to the transfer of burden among members of the health care team, quality of education, clinician involvement, and evaluation methods.

Keywords

electronic health record - documentation - documentation burden

• References

• 1 Murthy VH. Addressing health worker burnout. US Department of Health and Human Services; 2022 . Accessed April 29, 2014 at: https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html
• 2 Hobensack M, Levy DR, Cato K. et al. 25 × 5 symposium to reduce documentation burden: report-out and call for action. Appl Clin Inform 2022; 13 (02) 439-446
• 3 Moy AJ, Schwartz JM, Chen R. et al. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. J Am Med Inform Assoc 2021; 28 (05) 998-1008
• 4 Rossetti SC, Rosenbloom S, Levy D. et al. Summary Report from the 25 By 5: Symposium Series to Reduce Documentation Burden on U.S. Clinicians by 75% by 2025; 2021. Accessed April 29, 2014 at: https://www.dbmi.columbia.edu/wp-content/uploads/2021/12/25×5-Summary-Report.pdf
• 5 Lindsay MR, Lytle K. Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Appl Clin Inform 2022; 13 (03) 711-719
• 6 Gesner E, Gazarian P, Dykes P. The burden and burnout in documenting patient care: an integrative literature review. Stud Health Technol Inform 2019; 264: 1194-1198
• 7 Collins S, Couture B, Kang MJ. et al. Quantifying and visualizing nursing flowsheet documentation burden in acute and critical care. AMIA Annu Symp Proc AMIA Symp 2018 ;2018: 348-357
• 8 Moy AJ, Schwartz JM, Withall J. et al. Clinician and health care leaders' experiences with-and perceptions of COVID-19 documentation reduction policies and practices. Appl Clin Inform 2021; 12 (05) 1061-1073
• 9 Levy DR, Sloss EA, Chartash D. et al. Reflections on the documentation burden reduction AMIA plenary session through the lens of 25 × 5. Appl Clin Inform 2023; 14 (01) 11-15
• 10 Steinkamp J, Kantrowitz JJ, Airan-Javia S. Prevalence and sources of duplicate information in the electronic medical record. JAMA Netw Open 2022; 5 (09) e2233348
• 11 Steinkamp J, Sharma A, Bala W, Kantrowitz JJ. A fully collaborative, noteless electronic medical record designed to minimize information chaos: software design and feasibility study. JMIR Form Res 2021; 5 (11) e23789
• 12 AMIA 25 × 5 | AMIA - American Medical Informatics Association. Accessed September 21, 2023 at: https://amia.org/about-amia/amia-25x5
• 13 Sengstack P, Adrian B, David RB, Boyd L, Davis A, Hook M. The six domains of burden: a conceptual framework to address the burden of documentation in the electronic health record. Position Paper of the American Nursing Informatics Association Board of Directors; 2020 . Accessed September 26, 2023 at: https://www.ania.org/assets/documents/position/ehrBurdenPosition.pdf
• 14 Ashton M. Getting Rid of Stupid Stuff: Reduce the Unnecessary Burdens for Clinicians. American Medical Association. 2019 . Accessed May 4, 2023 at: https://edhub.ama-assn.org/steps-forward/module/2757858
• 15 Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014; 12 (06) 573-576
• 16 Strategy on reducing burden relating to the use of health IT and EHRs | HealthIT.gov. Accessed May 4, 2023 at: https://www.healthit.gov/topic/usability-and-provider-burden/strategy-reducing-burden-relating-use-health-it-and-ehrs
• 17 Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid-Based Healthc 2015; 13 (03) 141-146
• 18 Tricco AC, Lillie E, Zarin W. et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018; 169 (07) 467-473
• 19 Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018; 18 (01) 143
• 20 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5 (01) 210
• 21 Health Systems Governance. Accessed January 30, 2024 at: https://www.who.int/health-topics/health-systems-governance
• 22 Kaizuka S, Maguire J, Sridhar S, Devine M, Nicandri G, Fogarty CT. Notes 2.0: reducing documentation burden. Fam Pract Manag 2022; 29 (04) 19-24
• 23 McDonnell B. Nurse EHR documentation coaching effort review and evaluation: a case study. J Inform Nurs 2022; 7 (01) 25-28
• 24 Rose A, Cooley A, Yap TL. et al. Increasing nursing documentation efficiency with wearable sensors for pressure injury prevention. Crit Care Nurse 2022; 42 (02) 14-22
• 25 Strudwick G, Jeffs L, Kemp J. et al. Identifying and adapting interventions to reduce documentation burden and improve nurses' efficiency in using electronic health record systems (The IDEA Study): protocol for a mixed methods study. BMC Nurs 2022; 21 (01) 213
• 26 Benko S, Idarraga AJ, Bohl DD, Hamid KS. Virtual scribe services decrease documentation burden without affecting patient satisfaction: a randomized controlled trial. Foot Ankle Spec 2022; 15 (03) 252-257
• 27 Tajirian T, Jankowicz D, Lo B. et al. Tackling the burden of electronic health record use among physicians in a mental health setting: physician engagement strategy. J Med Internet Res 2022; 24 (03) e32800
• 28 Englebright J, Michel S, Boyd DL, Hulett SL. A framework for national collaboration to reduce documentation burden and design for usable and reusable data. J Nurs Adm 2021; 51 (03) 162-167
• 29 Phillips T, Baur K. Nursing praxis for reducing documentation burden within nursing admission assessments. Comput Inform Nurs 2021; 39 (11) 627-633
• 30 Pallansch J, Belyshev V, Longerstaey O. Streamlined point-of-care ultrasound electronic worksheet effects on provider satisfaction and completion time. Acad Emerg Med 2021; 28: S357
• 31 Otokiti AU, Craven CK, Shetreat-Klein A, Cohen S, Darrow B. Beyond getting rid of stupid stuff in the electronic health record (Beyond-GROSS): protocol for a user-centered, mixed-method intervention to improve the electronic health record system. JMIR Res Protoc 2021; 10 (03) e25148
• 32 McIlreevy J, Rylee TL, Shields-Tettamanti T, Gee PM. Interdisciplinary optimization of admission documentation: reducing the bloat. Comput Inform Nurs 2021; 39 (05) 248-256
• 33 Lee SK, Chang JH, Lee J, Seng SS, Namm JP, Lum SS. Medical scribes-help or hindrance? Attending and trainee satisfaction with scribes in outpatient academic surgery clinics. J Am Coll Surg 2021; 233 (05) S227
• 34 Kumah-Crystal YA, Stein PM, Chen Q. et al. Before-visit questionnaire: a tool to augment communication and decrease provider documentation burden in pediatric diabetes. Appl Clin Inform 2021; 12 (05) 969-978
• 35 Horn JJ, Doucette JN, Sweeney NL. An essential clinical dataset intervention for nursing documentation of a pediatric admission history database. J Pediatr Nurs 2021; 59: 110-114
• 36 Corby S, Ash JS, Mohan V. et al. A qualitative study of provider burnout: do medical scribes hinder or help?. JAMIA Open 2021; 4 (03) ooab047
• 37 AAFP innovation lab: reducing documentation burden through the use of a digital assistant. Fam Pract Manag 2021; 28 (04) 8-11
• 38 Dymek C, Kim B, Melton GB, Payne TH, Singh H, Hsiao CJ. Building the evidence-base to reduce electronic health record-related clinician burden. J Am Med Inform Assoc 2021; 28 (05) 1057-1061
• 39 Kaufman DR, Sheehan B, Stetson P. et al. Natural language processing-enabled and conventional data capture methods for input to electronic health records: a comparative usability study. JMIR Med Inform 2016; 4 (04) e35
• 40 Guo U, Chen L, Mehta PH. Electronic health record innovations: Helping physicians - one less click at a time. HIM J 2017; 46 (03) 140-144
• 41 Leventhal R. How natural language processing is helping to revitalize physician documentation. Healthc Inform 2017; 34 (05) 8-13
• 42 Mehta S, Johnston R, Yadav S, Cadotte R, Maranda M, Mogannam J. Scribes in hospital medicine-a powerful value-added resource!. J Hosp Med 2018; 13 (04) U2-L629665584
• 43 Mishra P, Kiang JC, Grant RW. Association of medical scribes in primary care with physician workflow and patient experience. JAMA Intern Med 2018; 178 (11) 1467-1472
• 44 Pozdnyakova A, Laiteerapong N, Volerman A. et al. Impact of medical scribes on physician and patient satisfaction in primary care. J Gen Intern Med 2018; 33 (07) 1109-1115
• 45 Tan GS, Rogers R, Stark R. Making epic your friend: a curricular innovation to improve the EMR experience in the clinic. J Gen Intern Med 2018; 33 (02) 725-726
• 46 Sieja A, Markley K, Pell J. et al. Optimization sprints: improving clinician satisfaction and teamwork by rapidly reducing electronic health record burden. Mayo Clin Proc 2019; 94 (05) 793-802
• 47 Dusek HL, Goldstein I, Hribar M, Chiang MF. Electronic health records in ophthalmology: impact of scribes on office visit length, documentation time, and note length. Invest Ophthalmol Vis Sci 2019; 60 (09) 5503
• 48 Kim A. 23.2 Working with medical scribes, medical assistants, and registered nurses to improve outpatient clinic workflow and support physician wellness. J Am Acad Child Adolesc Psychiatry 2019; 58 (10) S33-S34
• 49 Swietlek M, Sengstack PP. An evaluation of nursing admission assessment documentation to identify opportunities for burden reduction. J Inform Nurs 2020; 5 (03) 6-11
• 50 Baxter SL, Gali HE, Chiang MF. et al. Promoting quality face-to-face communication during ophthalmology encounters in the electronic health record era. Appl Clin Inform 2020; 11 (01) 130-141
• 51 Hunt RJ, Fletcher S, Rock JP, Air EL. More time for doctoring: reduction of resident daily documentation burden. Neurosurgery 2020; 67 (Suppl. 01)
• 52 Russell CK, Floyd CT, Ledwell L, Morgan S. A community hospital's approach to alleviate documentation burden. J Inform Nurs 2020; 5 (02) 8-12
• 53 Sutton DE, Fogel JR, Giard AS, Gulker LA, Ivory CH, Rosa AM. Defining an essential clinical dataset for admission patient history to reduce nursing documentation burden. Appl Clin Inform 2020; 11 (03) 464-473
• 54 Soegaard Ballester JM, Bass GD, Urbani R. et al. A mobile, electronic health record-connected application for managing team workflows in inpatient care. Appl Clin Inform 2021; 12 (05) 1120-1134
• 55 Zhang P, Kamel Boulos MN. Generative AI in medicine and healthcare: promises, opportunities and challenges. Future Internet 2023; 15 (09) 286
• 56 Xue VW, Lei P, Cho WC. The potential impact of ChatGPT in clinical and translational medicine. Clin Transl Med 2023; 13 (03) e1216
• 57 Wachter RM, Brynjolfsson E. Will generative artificial intelligence deliver on its promise in health care?. JAMA 2024; 331 (01) 65-69