A broad variety of healthcare workers author and view notes in the electronic health record. Clinical notes serve several purposes. They augment the author's memory, create a longitudinal record for continuity of care, provide communication between users, support quality assurance, substantiate billing, serve as legal documentation, and support research and education. About a sixth of notes overall go unread, thus playing no direct role in communication, but an unread note may still be useful because of its potential for future use and because of legal requirements. About a third of nursing notes go unread; this higher rate may be due to the use of oral communication between successive nursing shifts and because much of the critical information is contained in flowsheets instead of nursing notes. Medical student notes were read by physicians at a relatively high rate of 81%, implying that supervision is substantial if not perfect.
The rate of attendings' and residents' notes being viewed by other attendings and residents (37–74% in ) corroborates earlier findings at a different medical center campus where physicians in the emergency department viewed clinical notes from previous encounters 47% of the time, given that they knew a note was available.18
The perception that clinical notes are difficult to find within an electronic health record 19
may contribute to incomplete note review.
Users spent a moderate amount of time authoring and viewing notes, with most less than 90 min per day in aggregate. In the literature, documentation has been reported as 21% of residents' time, 12% of attendings' time, and 7% of emergency nurses' time.13
Other studies have reported that family practitioners spend 1.2 h per day documenting,14
and oncologists spend 1.4 h per day documenting.15
In 1997, internal medicine residents who were on call were reported to have spent 2.6 h on paper chart review and 2.2 h on paper documentation, with an additional half hour on the computer.20
Our results contradict a study of medical resident's perceptions of time spent on documentation.4
We found 65 min per day, whereas residents perceived spending over 4 h. This is likely due to the survey including order entry in the definition of ‘documentation.’ There is also likely a difference between perception and measured rates. The same study4
found that medical residents received feedback on documentation less than 50% of the time. Our findings, shown in , reveal that attendings review residents' notes less than 50% of the time, corroborating this earlier study.
The use of notes over time, shown in , has implications for system builders. The use of notes drops off rapidly after the first day, but even old notes (up to almost 2 years in this study) got viewed at a low but consistent rate. This implies that recent notes should be the most easily accessible, but that older notes should remain accessible for at least 2 years. As one might expect, summary notes like admission notes become relatively more important than progress notes over time. The proven redundancy among progress notes21
explains some of the per-note drop off: once one progress note is viewed, adjacent ones become less important. Nevertheless, progress notes are still viewed at a measurable rate after a year. Therefore, even progress notes should be retained in the record for some time.
provides relevant information about intergroup communication. Attendings and residents review nursing and social work notes less than a third of the time. This may point to an opportunity for the electronic health record to summarize information and make it readily available, perhaps with the ability of the author to highlight information that may be critical and that has a high priority for communication. Nurses appear to be reviewing attending and resident information at a higher rate. Communication rates within groups tend to be higher, perhaps reflecting the strong relevance of clinical information within groups.
In this medical center, the core care team comprised one or more attendings, residents, and nurses, with a social worker joining the team soon after. Dieticians and therapists tended to join the team later in the stay. Within these teams, the tightest bilateral communication occurred between members of the same user group and between attendings and residents.
The study has several limitations. The study did not capture in-person or telephone conversations. Therefore, some of the uncovered lapses in communication may be met orally. For example, critical results may be more likely to be communicated orally and immediately. While this study limitation is important, the results remain useful, as they represent trends, and the rates may be compared to each other. Another limitation is that we are inferring actions and intentions from artifacts like notes and logs of keystrokes; for example, system idle time while a user carries out other tasks may be counted as authoring or viewing time. A full time–motion study with concrete observation of user activity coupled with a think-aloud protocol to elicit intentions would complement this one. Such a study would reveal deep information about a small number of clinical interactions, while our present study permits a broad view of activity across many user types. As noted above, the documentation analysis excluded nursing flowsheets because of the way they are incorporated into the application, and this will cause an underestimate of nursing documentation time and can affect the analysis of communications. The study was conducted at a single academic medical center, reflecting the workflow of a single institution; a multicenter study would improve generalizability.