Comparing audiovisual visit and in-person visit note quality

Area of Science:

• Medical Informatics
• Clinical Documentation
• Primary Care Research

Background:

• The COVID-19 pandemic significantly increased the use of audiovisual medical visits, which remain more frequent than pre-pandemic levels.
• Audiovisual visits represent a growing clinical modality, yet their clinical note quality remains under-investigated.
• Previous research has explored various aspects of audiovisual visits, but not the quality of associated clinical documentation.

Purpose of the Study:

• To evaluate and compare the clinical note quality of audiovisual visits versus traditional in-person visits.
• To identify differences in the quality of key components within clinical notes from different visit modalities.

Main Methods:

• A random sample of 100 audiovisual and 100 in-person primary care visits for type 2 diabetic patients in 2021 was selected.
• The QNOTE instrument, a validated tool for assessing clinical note quality, was utilized.
• Seven experienced primary care physicians rated four critical elements: chief complaint, history of present illness, assessment, and plan.

Main Results:

• Audiovisual visit notes scored significantly lower overall (75.8/100) compared to in-person notes (86.5/100) (P < .0001).
• Specific components like chief complaint (72.4 vs 83.0) and history of present illness (63.7 vs 82.5) showed marked differences in quality.
• Assessment and plan sections also demonstrated lower scores for audiovisual visits, though the difference was less pronounced.

Conclusions:

• Clinical notes from audiovisual visits exhibit lower quality than those from in-person visits.
• This study provides the initial evidence comparing the documentation quality between audiovisual and in-person clinical encounters.
• Findings highlight a need to address potential quality gaps in clinical notes generated during remote patient care.