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Variation in Physicians’ Electronic Health Record Documentation and Potential Patient Harm from That Variation

  • Genna R. CohenEmail author
  • Charles P. Friedman
  • Andrew M. Ryan
  • Caroline R. Richardson
  • Julia Adler-Milstein
Original Research

Abstract

Background

Physician-to-physician variation in electronic health record (EHR) documentation not driven by patients’ clinical status could be harmful.

Objective

Measure variation in completion of common clinical documentation domains. Identify perceived causes and effects of variation and strategies to mitigate negative effects.

Design

Sequential, explanatory, mixed methods using log data from a commercial EHR vendor and semi-structured interviews with outpatient primary care practices.

Participants

Quantitative: 170,332 encounters led by 809 physicians in 237 practices. Qualitative: 40 interviewees in 10 practices.

Main Measures

Interquartile range (IQR) of the proportion of encounters in which a physician completed documentation, for each documentation category. Multilevel linear regression measured the proportion of variation at the physician level.

Key Results

Five clinical documentation categories had substantial and statistically significant (p < 0.001) variation at the physician level after accounting for state, organization, and practice levels: (1) discussing results (IQR = 50.8%, proportion of variation explained by physician level = 78.1%); (2) assessment and diagnosis (IQR = 60.4%, physician-level variation = 76.0%); (3) problem list (IQR = 73.1%, physician-level variation = 70.1%); (4) review of systems (IQR = 62.3%, physician-level variation = 67.7%); and (5) social history (IQR = 53.3%, physician-level variation = 62.2%). Drivers of variation from interviews included user preferences and EHR designs with multiple places to record similar information. Variation was perceived to create documentation inefficiencies and risk patient harm due to missed or misinterpreted information. Mitigation strategies included targeted user training during EHR implementation and practice meetings focused on documentation standardization.

Conclusions

Physician-to-physician variation in EHR documentation impedes effective and safe use of EHRs, but there are potential strategies to mitigate negative consequences.

KEY WORDS

EHR documentation mixed methods primary care 

Notes

Funding Source

Funded by the Agency for Healthcare Research and Quality (1R36HS023719-01A1), the University of Michigan Rackham Predoctoral Fellowship, and the University of Michigan McNerney Award.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Genna R. Cohen
    • 1
    Email author
  • Charles P. Friedman
    • 2
  • Andrew M. Ryan
    • 3
  • Caroline R. Richardson
    • 4
  • Julia Adler-Milstein
    • 5
  1. 1.MathematicaWashingtonUSA
  2. 2.Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborUSA
  3. 3.Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborUSA
  4. 4.Department of Family MedicineUniversity of Michigan Health SystemAnn ArborUSA
  5. 5.Center for Clinical Informatics and Improvement ResearchUniversity of California San Francisco Department of MedicineSan FranciscoUSA

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