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.

The Public Libraries are Opening! The Public Libraries are Opening!

Of all the wonderful signs and sounds heralding a change in the response to the COVID-19 pandemic, none is more welcome than the news that public libraries are reopening. If you, like me, remember spending hot summer afternoons in the cool, air-conditioned library, this mid-summer news may bring a smile to your face. For me, as NLM director, this means that NLM will once again have another pathway to help people all over the country access the resources of NLM from their community library.

As public libraries closed their buildings during the pandemic, library staff continued to serve their communities in innovative ways, including home delivery of library books by bike from the Hinsdale Public Library. The joys of reopening are shared by patrons and staff alike, as illustrated in this photo essay from The New York Times:

Working in libraries “feels like home,” Mishael Gis, 28 [a patron], told me. She was using a computer for taxes and research. The scene felt like a homecoming.

Michael Rios, 45, a librarian for children, has spent the pandemic helping readers remotely. But what he likes is helping kids find the unexpected: “I help people search, physically. That’s the part that speaks to me. So, this is great. Huge.”

NLM has a special relationship with public libraries. Many public libraries are members of our Network of the National Library of Medicine (NNLM) and have access to, through NNLM’s seven Regional Medical Libraries, specialized training and resources that enable patrons to tap into the resources and knowledge base of NLM. As members of the NNLM, staff of those libraries have access to hundreds of courses and learning resources provided at no cost, bringing new knowledge about data science and communicating health information to a wide range of audiences.

Public libraries also provide NLM with a ‘finger on the pulse’ of communities around the nation. This helps us understand what kinds of health information are most valued and how to best deliver it.

NLM’s relationship with public libraries supports NIH and provides a mutually beneficial way to leverage partnerships around the country and bring information and opportunities about NIH research programs into communities. For more than 5 years, our NNLM has partnered with NIH’s All of Us Research Program to provide community-based information about participating in this ambitious effort. All of Us is building a diverse community of more than 1 million participants across the country to help researchers learn more about how genetics, environment, and lifestyles affect individuals’ health, especially those in communities who have historically been excluded from large-scale research programs. During the COVID-19 pandemic, the NNLM also partnered with the NIH Community Engagement Alliance (CEAL) Against COVID-19 Disparities to use community-engaged strategies to reduce the burden of COVID-19 among communities disproportionately affected.

Come celebrate with me! The public libraries are opening! The public libraries are opening!

Preparing for the Best Future We Can Imagine

Last year we published a blog on my birthday . . .  I love my birthday! As I wrote last year  . . . When you grow up in a family of 10 kids, like I did, your birthday is a very special day. I celebrated my birthday last week and spent time with my dear friend, Viki, and took the opportunity to celebrate my life yet lived. 

At this point in my life, I find myself consumed with the awareness of how precious life is and how short it feels. The pandemic aggravated a sense that people are vulnerable, life is fragile, and there’s not much time. This sensation made me feel rather depressed. I’m not quite sure why as it’s been a busy and productive year. 

Over the past year, NLM accomplished so much by helping the NIH build the data infrastructure for genomic discovery to better respond to the COVID-19 pandemic and prepare for future ones; conducting research on the microbiome; and determining whether we could detect the presence of certain viruses, including SARS-CoV-2, through the analysis of wastewater. We funded new research to make it easier to understand health data and supported more than 300 trainees and fellows through our Extramural Programs Division. We learned how to telework and meet virtually. We kept our highly valued products and services open and operational 24 hours, 7 days a week. We onboarded new staff, said goodbye to coworkers who retired or moved on, and mourned the deaths of several colleagues.

Slowly, as we’ve all been emerging from the pandemic shutdown to discover new ways of being, I find my spirits lifting and my eyes looking towards the future with optimism and joy.

Part of this feeling comes from a deep and respectful pride for NLM’s accomplishments over the year, and the role I’ve played in it. Some of it comes from welcoming new children and spouses into my very large family. A lot of it comes from the sense of purposeful living that helped me transform a sense of isolation to an engagement with others to co-create a new future. What I’ve realized is that we never actually know our future, so preparing for the best future we can imagine is probably the smartest strategy.

This year, as I add another digit to the long lists of digits that I’ve already accumulated, I’m preparing for the best future that I can imagine. I’m exercising more, practicing the piano with greater diligence, and spending meaningful time with friends and family. I’m engaging with NLM leadership and staff to envision the future of work and to enhance the inclusivity and diversity of our work environment.

I’ve somehow managed to shake off the sense of gloom and doom and see a future that appears limitless to me—awaiting what I can be bold enough to envision, create, and accomplish. Please join me in celebrating my birthday and stepping into the future.

What Did You Do with Your Summer Vacation?

Well, if you are spending the summer at the NIH, you’ve likely been engaged in one of our many activities designed to access critical data and advance our understanding of the human experience by linking data sets together. Today, we are inviting you to engage in some additional best practices in accessing controlled data in ways that support science and preserve privacy.

In 2020, the NIH Scientific Data Council charged its Working Group for Streamlining Access to Controlled Data to spend a year engaging in dialogue within the NIH and with our extramural colleagues to better understand the experiences of scientists and the strategies that both facilitate and impede access to data. The group also considered where in the research process NIH should inform, engage, and gain consent of participants sufficiently to support science driven by access to controlled datasets.

NIH stores and facilitates access to many datasets, both open and controlled, with the goal of accelerating new discoveries and thereby maximizing taxpayer return on investment in the collection of these datasets. Data derived from humans that are shared through controlled-access mechanisms reflect NIH’s commitment to protect sensitive data and honor the informed consent provided by research participants in NIH-supported studies.

NIH has supported multiple controlled-access data repositories that uphold appropriate data protections for both human data and other sensitive data, while meeting the needs of various researcher communities. However, as data access requests increase, new repositories are established, and new mechanisms of providing access to data are developed, it is apparent that opportunities remain to improve efficiency and harmonization among repositories to make NIH-supported controlled-access data more FAIR: Findable, Accessible, Interoperable, and Reusable and to ensure appropriate oversight when data from different resources are combined. While these trends are enabling datasets and datatypes to be combined in new ways that advance the science, datasets, and datatypes that may or may not be controlled may, when combined, create inadvertent re-identification risks.

To help the agency address these issues in a way that is responsive to community needs, we are hosting a series of webinars through the end of July. We call these “breakout sessions” because they follow an outstanding webinar presented on July 9 available here. Richard Hodes, MD, director of the National Institute on Aging, launched the 3-hour seminar with a talk titled Opportunities for Advancing Research Through Better Access to Controlled Data. Ana Navas-Acien, MD, PhD, brought the perspective of indigenous and communities of people traditionally underrepresented in research, and she emphasized themes of community engagement and broadening the consent framework to consider community-level accountabilities as well as individual assent. Lucila Ohno-Machado, MD, MBA, PhD, addressed privacy preserving distributed analytics as a strategy to promote science while preserving privacy of data. Hoon Cho, PhD, described privacy-enhancing computational approaches to privacy preservation.

You can find the schedule for the breakout sessions below. These sessions are specifically designed to listen to the expectations, hopes, and concerns from researchers and participants. These webinars are free and open to the public; registration is required.

Breakout Session on “Making Controlled-Access Data Readily Findable and Accessible” on July 22 from 3 pm to 5:30 pm EST

Breakout Session on “General Opportunities for Streamlining Access to Controlled Data” on July 26 from 12:30 pm to 2 pm EST

Breakout Session on “Addressing Oversight, Governance, and Privacy Issues in Linking Controlled Access Data from Different Resources” on July 28 from 3 pm to 5:30 pm EST

To generate interest and hear from the broadest possible group of stakeholders, NIH has released a Request for Information on Streamlining Access to Controlled Data from NIH Data Repositories. Please note the closing date is August 9. We look forward to hearing from you! Please visit Streamlining Access to Controlled Data at the NIH for all of the information described in this post.

Finally, we would like to personally thank the many NIH staff members who serve on the working group:

  • Shu Hui Chen
  • Alicia Chou
  • Valentina Di Francesco
  • Greg Farber
  • Jamie Guidry Auvil
  • Nicole Garbarini
  • Lyric Jorgenson
  • Punam Mathur
  • Vivian Ota Wang
  • Jonathan Pollock
  • Rebecca Rodriguez
  • Alex Rosenthal
  • Steve Sherry
  • Julia Slutsman
  • Erin Walker
  • Alison Yao

I hope your summer vacation was as productive as ours!

(left to right)
Patricia Flatley Brennan, RN, PhD, NLM Director
Susan Gregurick, PhD, Associate Director for Data Science at NIH
Hilary S. Leeds, JD, Senior Health Science Policy Analyst for the Office of Science Policy at NIH

(Re)Engineering the National Library of Medicine Building

Guest post by Dianne Babski, Associate Director for Library Operations and Patrick Casey, NLM Building Engineer

NLM, the largest biomedical library in the world, is housed in Buildings 38 and 38A on the NIH campus in Bethesda, Maryland. As we head into our third century of existence, we are guided by our ten year NLM Strategic Plan, which outlines a vision for NLM as a platform for biomedical discovery and data-powered health, integrating streams of complex and interconnected research outputs that can be readily translated into scientific insights, clinical care, public health practices, and personal wellness.

An important step in realizing this future is to create a physical environment to better position NLM to fulfill the goals of its strategic plan. In Fall 2017, we engaged with NIH facilities management, architects, and historic preservation specialists to explore ways to better utilize our space, support research, and provide a progressive and collaborative work environment. Through an iterative and cooperative process, including engagement with and feedback from our many stakeholders, the needs expressed became the drivers for the recommendations and plans made for the proposed future of NLM.

Little did we know when we embarked on this extensive renovation that the project would take a twist – a global pandemic. In some ways, the pandemic provided an opportunity to recognize the extent of work that could still continue with many staff working remotely.

As we enter the first phase of the renovation project, that involves the Mezzanine level and 1st floor in Building 38, I thought it would be helpful to learn more about the project from the perspective of the person overseeing it – Patrick Casey, NLM’s building engineer. I had an opportunity to sit down with Patrick to ask some questions and get his thoughts on the project.


What have you found most interesting about the NLM renovation compared to other projects you’ve worked on?

Figure 1: The exterior view of the National Library of Medicine and Lister Hill Center.

NLM has a lot more people and building space than I would have assumed. The main building space (Building 38) is unique given its historical context and details. It was built in a very different era, and this renovation project is attempting to reutilize the space in a more modern way.

The main building was built in the 1950s in a construction fashion that is not done anymore, and it’s a building constructed using a lot of concrete. I’ve heard many stories about the construction of the building, one of which is that it was built as a bomb shelter to enable it to withstand a bomb attack to protect the collections.

What makes the NLM building renovation necessary and distinctive?

Figure 2: NLM’s Main Reading Room (before renovations).

This renovation is necessary to make better use of existing space, create new space for growing research programs, ensure the integrity of NLM’s collections, and support the future work of NLM. The breadth of the project is a treat to work on because there is never a shortage of things to do.

All of the various projects at NLM have unique characteristics. NLM facilities house the historical collections, a 24-hour data center, and a 10-story administrative facility supported by several stories below ground.

While the main building was built in the 1950s, Building 38A was added in the 1970s. While newer than the original Library building, Building 38A is also showing its age and “time stamp” from that era of building design.

What have you had to learn as part of this project?

Figure 3: NLM’s Main Reading Room (during renovations).

This is NLM’s first major renovation in 50 years, and we’ve had to learn a lot about some of the interesting challenges that exist with the building, including unique climate control concerns that need to be considered and addressed—especially on levels where historical collections are stored.

The project management process is constantly keeping us on our toes because there are a lot of things to plan. We do not typically have much down time.

What are you most excited to see at the end of the renovation?

I look forward to seeing how the new renovation does the building justice in terms of maintaining its unique qualities while providing staff with a modernized, 21st century work environment to facilitate collaboration, and creating a welcoming environment for visitors and patrons. I am excited to see the spaces open and ready for people to use and move into. That said, work will continue after this major renovation project is complete. Building system upgrades needed to improve environmental conditions will continue to be addressed. Tackling these improvements will introduce its own set of challenges, and I look forward to it.


We are very lucky to have an engineer on staff to help NLM oversee these major renovations, keep us informed of what’s going on, and help us continue to modernize and improve our work areas as we build for the vision of our future!

We would love to hear your tips or lessons learned if you went through renovations!

Ms. Babski is responsible for overall management of one of NLM’s largest divisions with more than 450 staff who provide health information services to a global audience of health care professionals, researchers, administrators, students, historians, patients, and the public

Mr. Casey is the NLM Building Engineer. He has worked for the federal government for nearly 19 years. Prior to working at NLM, he worked in various capacities at the Navy and Marine Corps working in facilities renovation and construction programs