Help is on the way: An initiative to Reduce Documentation Burden on US Clinicians by 75% by 2025

By Susan McBride, Ph.D., RN-BC, CHPIMS, FAAN Professor and Program Director Masters in Nursing Informatics, Texas Tech University Health Sciences Center School of Nursing

By Mari Tietze, PhD, RN-BC, FHIMSS, FAAN Professor Doswell Endowed Chair in Nursing Informatics Program Coordinator, Post-Baccalaureate Certificate in Interprofessional Informatics

The adoption of health information technology has been identified as the panacea for the US healthcare system’s patient safety and quality challenges identified almost two decades ago in the National Academy of Medicine’s* well-documented findings.^1,2 The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 establishing Electronic Health Records (EHRs) throughout the nation is now followed by the 21^st Century Cures Act. The massive and rapid adoption of EHRs has burdened clinicians due to design, configuration, and implementation issues. These challenges result in poor usability, clinical workflow challenges, and the burden of documentation.³

To address these challenges, The National Library of Medicine funded an initiative focused on reducing documentation burden by 75% by 2025 for US clinicians. The initiative “25 by 5: Symposium to Reduce Documentation Burden on US Clinicians by 75% by 2025” had the following specific goals:

1. Engage a diverse group of key stakeholders and leaders focused on reducing documentation burden. Stakeholders included federal agency representatives from the Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and the Office of the National Coordinator for Health Information Technology.
2. Assess the likely potential for burden reduction within categories of documentation burden, including identifying ‘low hanging fruit’ for ‘quick wins’ without adversely impacting quality or access to care.
3. Establish approaches for immediate (<3 months) and short-term (6 months) reduction in clinical documentation burden.
4. Generate approaches to longer-term (10 years) elimination of clinical documentation burden.⁴

Principles of engagement were particularly notable. The first principle was to leverage technology and existing data inputs where appropriate. The second was no erosion of care standards. The third was to maximize clarity of proposed rules to minimize misinterpretation by health systems and providers. The fourth was no wholesale shifting of work from one clinician to another, seeking to eliminate unnecessary documentation.⁴ As a result of the symposium, a report is being written summarizing major findings and recommendations due out later this year. The website for the initiative is located as follows: https://www.dbmi.columbia.edu/25x5/ 

The Texas Nurses Association (TNA)-Texas Organization of Nursing Leaders (TONL) Health Information Technology Committee had representation at the symposium and presented some findings from the TNA-TONL “Statewide Study on Nurses Experiences with their EHRs.” This statewide study was initially conducted in 2015 with a follow-up study in 2020. The topic contributed by the TNA-TONL representative was “Too Many Clicks.” Findings related to nurses responding to the statewide study in 2015 and the follow-up study in 2020 supported the presentation and recommendations. Nurses and clinicians told us there is an overabundance of clicking and movement from screen to screen to document clinical care. The goal of EHR implementation should be to balance too many clicks with quality clinical documentation. Data emphasizing Texas nurses’ responses to an open-ended question within the statewide survey was particularly revealing. The statewide study requested that nurses contribute any additional information that was not covered in the survey’s standard questions. These open-ended statements resulted in reflections of many insightful experiences regarding “too many clicks.” An example of these types of statements are:

• “Viewing a specific order takes CLICKing thru at least four screens to find out what the nurse really needs to know. I feel patient safety is at risk because the nurse could miss something very important because he/she did not open up every specific screen.”
• “…computer charting instills education on what to CLICK, not on free thinking.”
• “The system is not user friendly. You have to CLICK here, CLICK there, and CLICK back again, and so on...in order to do just ONE assessment.”

Additional information shared related to nurses experiencing challenges that precipitate potential Texas Board of Nurses actions with licensure implications. From 2007 to 2018, the Texas Board of Nurses saw increases in citations that included documentation and reporting requirements as a standard of practice. While we cannot determine which orders contained violations involving documentation in the EHR, reporting or both, it is clear from the control chart in Figure 1 that special cause variation is present (reflected in rule violations within the control chart). At the same time of these significant increases over the years, we would be experiencing a steep climb in EHR implementations across the state of Texas.

Figure 1. Texas Board of Nursing (2019). Texas Board of Nursing Data on counts of orders for citations of 22 TAC 217.11(1)(D).

In closing, a coordinated approach to addressing significant issues with EHRs for Texas nurses is in order. The 25X5 initiative holds promise in addressing the documentation burden; however, nursing leadership must be represented in this national conversation. The TNA-TONL Health IT committee has been in place for over ten years with extensive, far-reaching delivery of health IT-related patient safety and quality education and interventions. The websites of both these organizations have housed the needed information. We call for the collaboration between practice and leadership of these two groups to be involved in the 25X5 initiative. That way, Texas nurses can be part of the process to help reduce documentation burden, reduce technology-based unintended consequences, and improve nurses overall wellbeing and joy in work.

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* previously the Institute of Medicine

References

1. IOM. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000.
2. IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.
3. Gettinger A, Zayas-Cabán T. HITECH to 21st century cures: clinician burden and evolving health IT policy. Journal of the American Medical Informatics Association. 2021.
4. Rossetti S, Rosenbloom T. 25 by 5: Symposium to Reduce Documentation Burden on US Clinicians by 75% by 2025. https://www.dbmi.columbia.edu/wp-content/uploads/2021/01/25x5-Symposium-Intro.pdf. Published 2021. Accessed March 24, 2021.