Note bloat, we can’t quit you

Last year, I?wrote?about how we physicians in the United States write much longer progress notes than our colleagues in every other country. As I noted in that article, this is not just an opinion that I hold but a fact that has been researched and demonstrated. Our notes are up to?four times longer?than similar documentation in nations with comparable economies. One might reasonably ask why we should compare ourselves by economy: Shouldn’t we look at peer healthcare systems instead? Alas, dear reader, we have none, and this is not something of which we should be proud.

Why is the documentation that American physicians create for patient progress notes so voluminous? The first reason that many of us come up with is the “evil” electronic health record (EHR). While it’s true that the EHR makes it easy to bring in oodles of discrete data from the record to populate in an individual note, we run into the difficult truth that doctors in other countries also use the exact same EHRs that we do (Epic, Oracle Health, and MEDITECH aren’t just used in the United States.) So, we can’t put all the blame there.

I’ve been a big proponent of blaming much of note bloat (first referenced in the academic literature?here) on the need for regulatory reform in the United States. Since 1995, physicians have been lectured on the need to count bullet points in their reviews of systems and physical exam descriptions. I can promise you that it gets boring fast. The compliance folks at our hospitals and healthcare systems have taught us that the penalties for not documenting everything – EVERYTHING – that occurred during a given encounter or visit can be severe.

Organized medicine and the federal government heard our pleas several years ago and updated the requirements for documentation that supports the charges we send to payers. In January 2021, the Centers for Medicare and Medicaid Services (CMS) introduced?streamlined updates?to what needs to be in an ambulatory progress note. Gone were former must-haves such as reviews of systems and even physical exam descriptions. In their place was an emphasis on the total time spent concerning that patient’s office visit or the depth of medical decision-making that took place. It wasn’t perfect, but it was a terrific improvement.

So, what happened in the last 2 1/2 years? Of course, the average note length was cut in half, and physicians (and those who must read their notes) jumped for joy. Actually, that’s only what I predicted would happen. What really happened? Our friends at Epic did some?research, and here’s what they found, “We evaluated 1.7 billion clinical notes written by 166,318 outpatient providers in the U.S. from May 2020 to April 2023 to determine the average length in characters for each note. We found that the average note length across all clinical notes has increased 8.1%, from 4,628 characters in May 2020 to 5,002 characters in April 2023 …” Ugh!

“I was going to write you a short letter but I didn’t have time, so I wrote a long one.”

There is some good news, however. The EHR vendor noted that while notes got bigger, the time to write them decreased, on average, from 5.4 minutes to 4.8 minutes – that’s 11% shorter. I guess that’s something. It reminds me of the quip that may – or may not – have come from Mark Twain, “I was going to write you a short letter but I didn’t have time, so I wrote a long one.” Quality, pithy writing takes time, whether it’s high-brow literature or describing the optimal plan for a patient with chronic heart failure.

Epic’s finding that, on average, note length went up while time in notes went down was also described in a JAMIA?article?from earlier this year, “Using a novel dataset of physician EHR use measures that capture note length, time in notes, and note composition, we found that decreasing note bloat and decreasing physician time in notes are distinct goals supported by different strategies of note composition.” Interestingly, these researchers found that “[d]ecreased time in notes is associated with team-based support, but not use of efficiency tools that leverage copied or templated text.” Epic’s article similarly showed that increased use of SmartTools (to bring in discrete data such as results or previous documentation) was associated with longer progress notes.

So what conclusions are we to draw from these data? Is it hopeless, and hence we should just learn to live with note bloat? That’s not an option. As noted in JAMA Network Open?research?from 2022, note bloat can lead to duplicative information in the EHR, which can cause data scatter, information overload, and clinician burnout. Doing nothing about note bloat is not acceptable.

When trying to solve a thorny problem, it’s often helpful to go back to basics to get at the root of the issue. In this case, I think it’s incumbent on physician leaders to take back our progress notes. Notes serve multiple, complex purposes, but at their essence, they are clinical tools and should be governed by clinicians. We should?formalize?what belongs in a note from a clinical perspective and then ensure that all physicians know what’s expected. This information shouldn’t come from hospital compliance and legal folks but instead from department chairs and chief medical officers.

While this may not be a popular take, I believe that leaders should regularly review a random sampling of notes as part of routine re-credentialing to make certain that documentation serves clinicians and their patients. Of course, minimal regulatory, legal, and quality aspects must be maintained, but we mustn’t let those needs take us back to 1995. We need to apply the human-centered design principle of making it easy to do the right thing. The right thing is to write short, concise, and helpful notes. Let’s recreate the system to achieve that end.