Electronic Patient Records, Real-Time Clinical Documentation and Burden: An Umbrella Review

Area of Science:

• Health Informatics
• Clinical Documentation
• Healthcare Management

Background:

• Electronic patient records (EPRs) are integral to modern healthcare.
• Clinicians face significant documentation burden (DB) with EPR use.
• Understanding this burden is crucial for effective healthcare delivery.

Purpose of the Study:

• To synthesize evidence on clinicians' documentation burden associated with EPRs.
• To map the causes of DB, barriers to real-time documentation, and technological solutions.
• To inform strategies for optimizing real-time EPR use and minimizing DB.

Main Methods:

• Umbrella review methodology.
• Searches across six databases yielding 2,739 records.
• Analysis guided by Donabedian's model (structure, process, outcomes) and Joanna Briggs Institute (JBI) methodology.

Main Results:

• Identified key factors contributing to documentation burden.
• Highlighted barriers hindering real-time documentation within EPR systems.
• Explored technological solutions aimed at alleviating clinician workload.

Conclusions:

• Findings provide a comprehensive overview of EPR-related documentation burden.
• Informs strategies to improve EPR usability and reduce clinician documentation burden.
• Aims to enhance efficiency and quality of care through optimized EPR implementation.