25×5: Decreasing Documentation Burden on U.S. Clinicians

Guest post by Sarah Rossetti, RN, PhD, FAAN, FACMI, FAMIA, and S. Trent Rosenbloom, MD, MPH, FACMI, FAMIA, Co-Chairs of the 25 By 5 Symposium

Health professionals are consistently being recognized for their heroic efforts to manage illness during the COVID-19 pandemic in the face of unprecedented challenges. As doctors, nurses, and all health care professionals faced their greatest challenges in more than a century, they did so while also dealing with the ongoing and increasing challenge of clinical documentation burden, which can be exacerbated by the widespread use of electronic health records systems.

The burden of clinical documentation on professionals has had a negative impact on health care since long before the first diagnosis of COVID-19. This burden can lead to a variety of negative outcomes including clinician burnout and decreased job satisfaction, medical errors, and hospital-acquired conditions. The pandemic increased recognition of the role of clinical documentation on workload. This recognition provided an opportunity to consider the contributions of inpatient and outpatient documentation on clinician well-being.

To establish strategies and approaches to reduce documentation burden on U.S. clinicians, we developed the 25 By 5 Symposium Series with the goal to reduce documentation burden to 25% of its current level by 2025. This symposium was sponsored by the American Medical Informatics Association, NLM, Columbia University Department of Medical Bioethics, and Vanderbilt Medical University Center.

The symposium, held virtually over six weeks in early 2021, addressed efforts to reduce clinical documentation burden, the associated challenges, and future innovations. More than 300 people representing clinical settings, academia, industry – electronic health record (EHR) vendors and start-up companies, government, payers, professional organizations, and patients participated in sessions featuring more than 30 presentations from stakeholders across health systems, academia, industry, government, payers, and professional societies.

Convening such a diverse group of key stakeholders and thought leaders resulted in the development of a national action plan focused on short, medium, and long-term approaches to reduce documentation burden to 25% by the year 2025.

To aid the work in addressing the complex issue of documentation burden, an organizing framework from the American Nursing Informatics Association 2020 Position Paper was used to outline the Six Domains of Burden.

These domains were used to organize breakout sessions and generate action items for reducing burden. An Executive Summary and Appendix of 82 Action Items from the Symposium are posted on the 25 By 5: Symposium website.

These action items are further categorized across four themes: 1) Accountability, 2) Evidence, 3) Education and Training, and 4) Innovation of Technology.

Action items—synthesized and prioritized in Calls to Action for key stakeholder groups — are highlighted below:

Call to Action for Providers and Health Systems

  • Establish guiding principles for adding documentation to EHRs and generating evidence for reduced documentation.
  • Develop a national roadshow and educate clinicians and clinicians in training on balancing brevity and completeness in documentation.
  • Increase support for functions like real-time information retrieval, documentation, and ordering in the EHR.
  • Implement interdisciplinary notes to decrease redundant documentation.

Call to Action for Health IT Vendors

  • Promote an ecosystem of interoperable systems to allow for complementary technology.
  • Develop measurement tools to categorize documentation practices.
  • Package best training practices into toolkits to promote best practice EHR use and plan recognition programs to publicize exemplars.
  • Create simplistic EHR views to see that new clinical data has been reviewed, then bookmark for the user and document as reviewed by that user in the EHR.
  • Implement user-personalized Clinical Decision Support to drive specific workflows.

Call to Action for Policy and Advocacy Groups

  • Urge agencies to fund innovative research that captures all billing code information without taking up clinicians’ time.
  • Select the best of breed approaches to documentation and implement throughout the health care system.
  • Develop technology to reliably and accurately create reimbursement/payment data for all care settings.

Now the hard work begins to turn these action items into change to benefit clinicians’ well-being and patient care.

This work will require the creation of a network of allies, convening sessions, and the creation of working groups from national health professional organizations in order to execute a national strategy for implementing and institutionalizing these changes.

Our clinicians are depending on concerted and coordinated engagement with key stakeholders from organizations within our health care community to mobilize strategies nationally.

On behalf of the 25 By 5 Symposium Steering Committee, we hope you will join us in this effort.

Funding sources: 
National Library of Medicine (1R13LM013581-01)
National Institute of Nursing Research (NINR): 1R01NR016941-01

Dr. Rossetti is an Assistant Professor of Biomedical Informatics and Nursing at Columbia University. Her research is focused on identifying and intervening on patient risk for harm by applying computational tools to mine and extract value from EHR data and leveraging user-centered design for patient-centered technologies.

Dr. Rosenbloom is the Vice Chair for Faculty Affairs and a Professor of Biomedical Informatics at Vanderbilt University. His research has focused on studying how health care providers, patients, and caregivers interact with health information technologies when documenting medical and health-related activities, and when making clinical decisions.

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