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Documentation Burden

NOMINATED TOPIC | June 3, 2022

1. What is the decision or change (e.g., clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

Documentation burden (both documenting and reviewing documents) contributes to clinician workloads, increased cognitive load, and has been found to negatively impact the quality of patient care delivered. The direct and indirect patient safety implications of documentation burden are not widely understood outside of the scientific community. A summary of evidence would be helpful as to how co-production of documentation improvement efforts with patients and caregivers could be successful. Moreover, it is a struggle to determine how best to measure improvements - how do we know that clinicians experience less burden? Understanding the evidence on measurement would be instrumental as improvement interventions are underway.

2. Why are you struggling with this issue?

We are struggling with this issue because documentation burden is multi-faceted. It involves various healthcare specialties and multi-disciplinary end users of documentation. Also, electronic health records, health systems, and provider offices may all have inherent design and functionality constraints that serve to perpetuate documentation inefficiencies. Strategies that are effective in one institution may not be widely disseminated or shared across others. With the persistent impact of COVID-19 on clinical processes, documentation burden is deservedly receiving greater attention as it is viewed as a contributor to reduced clinician wellness. And as we move to the co-production of healthcare and shared decision making, the patient's role in improving documentation is key; especially since we don't want to see documentation burden being shifted to patients.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

The implementation of initiatives to reduce clinician documentation burden is critical and timely. However, measurement remains challenging when comparing institutions. Also, data collection methods regarding EHR optimization efforts can be highly resource intensive. Understanding the evidence related to universal measurement tools or frameworks is necessary to know that the issue is improving.

4. When do you need the evidence report?

Tue, 12/03/2024

5. What will you do with the evidence report?

The AMIA 25X5 Task Force Reducing Documentation Burden aims to reduce the existing burden to 25% by 2025. Intervention planning is underway, but a full understanding of the measurement needs and the role of patients will be important to share with pilot sites and other related initiatives. The Task Force is in a position to develop, collaborate, and disseminate potential incremental documentation burden strategies.

Optional Information About You

What is your role or perspective? Clinician, Professional Society

If you are you making a suggestion on behalf of an organization, please state the name of the organization AMIA 25X5 Task Force

May we contact you if we have questions about your nomination? Yes

Page last reviewed June 2022
Page originally created June 2022

Internet Citation: Documentation Burden. Content last reviewed June 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/get-involved/nominated-topics/documentation-burden

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