Electronic health records improve clinical note quality

Area of Science:

• Medical Informatics
• Clinical Documentation Improvement
• Health Services Research

Background:

• Clinical notes are vital for patient care and administrative tasks.
• The impact of Electronic Health Records (EHRs) on clinical note quality remains under investigation.
• This study addresses the need to evaluate EHR effectiveness in improving outpatient clinical note quality.

Purpose of the Study:

• To determine if EHR implementation improves the quality of outpatient clinical notes.
• To quantify changes in clinical note quality at different time points post-EHR adoption.

Main Methods:

• A 5.5-year longitudinal, retrospective, multicenter quantitative study.
• Compared handwritten notes (before EHR) with electronic notes (after EHR and 5-year EHR) for 100 patients with type 2 diabetes.
• Utilized the validated QNOTE instrument, with 16 primary care physicians assessing 300 notes.

Main Results:

• Mean QNOTE scores increased from 52.0 (before EHR) to 61.2 (after EHR) and 80.4 (5-year EHR).
• Significant improvements of 18% (before-after) and 55% (before-5-year) were observed (p<0.0001).
• All assessed elements and overall quality scores showed significant improvement over the 5-year period.

Conclusions:

• EHRs significantly enhance the overall quality of outpatient clinical notes.
• Improvements were noted across all elements, including core and non-core components.
• This study provides novel evidence of EHRs' positive impact on clinical note quality.