The Impact of Outpatient Documentation Standardization on Internal Medicine Resident Efficiency and Well-Being

Documentation in the electronic health record (EHR) is frequently cited as a primary reason for burnout among physicians.

To determine if standardization of documentation in the outpatient setting improved resident EHR efficiency and well-being.

Pre-post difference-in-differences evaluation of EHR efficiency metrics comparing intervention residents with a historical control group; pre-post survey on well-being for intervention residents.

Fifty-two post-graduate year (PGY) 2 and 55 PGY3 internal medicine residents compared with 55 PGY2 and 49 PGY3 historical controls at an urban academic clinic.

Standardized documentation templates and medication ordering practices and mandatory training on their use, with incentivized opportunities to practice documentation methods.

Time spent per appointment in chart review, note writing, and placing orders; length of notes measured in characters; number of characters of text copied from prior notes and pasted into the current note (copy/paste text); Mini-Z well-being survey assessed pre- and post-intervention implementation aggregated for PGY2 and PGY3 residents.

The intervention was associated with an 18.8-min and 12.0-min decrease in per-encounter documentation time for residents during their PGY2 year (p < 0.0001) and PGY3 year, respectively (p < 0.0001). Standardization was associated with a decrease in note length of 3650 characters (43.3%) for PGY2 residents (p < 0.0001) and 1608 characters (17.7%) for PGY3 residents (p < 0.0001), as well as a 66.7% and 74.6% decrease in copy/paste text for PGY2 (p < 0.0001) and PGY3 (p < 0.0001) residents, respectively. Among clinic residents completing pre (N = 42) and post (N = 28) surveys, there were no significant changes in Mini-Z scores, though the single item question on burnout improved from 3.2 pre-intervention to 3.7 post-intervention (p = 0.01).

Documentation standardization was associated with significant decreases in documentation time per visit, note length, and percentage of copy-paste text among PGY2 and PGY3 resident physicians. No change was detected on well-being metrics; however, analysis was limited by low response rate to well-being questions.