What Duplicate Patient Notes Reveal About Health Care and Its Records

Bloat in patient notes has been alarming doctors for some time. The American Medical Informatics Association began a project to reduce patient documentation to 25% of its current volume by 2025. This task won’t be solved by any single organizer or sector; the AMIA calls on providers and health systems, Health IT vendors, and policy and advocacy groups to join the effort. A recent study in a JAMA publication, “Prevalence and Sources of Duplicate Information in the Electronic Medical Record,” helps drive discussion of bloat forward by focusing on one manifestation: the duplication of text from one patient note to another. Fully half of all notes, the authors find, consist of text copied from previous notes. (Side Note: Check out this video interview on Physician Burnout with one of the authors.) To establish what’s a duplicate, the authors checked for 10-word sequences that were exactly the same in different notes for the same patient. This seems to me a reasonable way to identify duplicates, although one can question what happens when an EHR automatically generates text. We’ll return to that issue later. The authors of the study couldn’t tell why clinicians write duplicate notes. That question would call for yet another study, which would interview the nurses and doctors themselves. And such a study might be hard to carry out. I informally polled some doctors I knew or was introduced to. Most failed to respond, probably because they were bus...
Source: EMR and HIPAA - Category: Information Technology Authors: Tags: AI/Machine Learning Ambulatory Clinical EMR-EHR Health IT Company Healthcare IT AdvancedMD Amazon Comprehend Medical AMIA billing CipherHealth Cloudticity Cumberland Heights Foundation Donna Pritchard Doug McGill EHR Document Source Type: blogs