Balancing Clinical and Administrative Needs in EHR Documentation Routines

Introduction: Electronic Health Record (EHR) systems serve multiple objectives, including to communicate clinically-relevant information, file billing claims, and serve as a legal record of rendered services. However, meeting the competing demands of these objectives can be cognitively demanding and time-consuming, especially in fast-paced, high-stakes settings like Acute Cae Surgery (ACS). Using ethnographic techniques, we evaluated how ACS providers balance competing clinical and administrative needs during documentation.

Methods: 90 hours of ethnographic observation and 13 semi-structured interviews with ACS providers were conducted. We employed a novel ‘pair fieldwork’ technique, whereby a surgeon and organizational sociologist conducted fieldwork together to contrast insider (‘emic’) and outsider (‘etic’) perspectives on documentation routines.

Results: Current documentation routines were more reflective of financial-legal considerations rather than the nuances of clinical decision-making. Providers found financial-legal requirements to be opaque and ill-defined, often charting “defensively” to minimize tedious billing/legal clarifications, billing ‘write-offs’, and potential legal issues. Opaque administrative requirements were identified as key contributing factors for ‘note-bloat’. Interviews with billing and compliance administrators revealed that they were equally frustrated with ‘note-bloat’ while also preferring clinically-focused notes. A shift from ‘systems-based charting’ to ‘problem-based charting’ was identified as a way to rebalance documentation routines toward clinical decision-making.

Conclusion: While current documentation routines appear to be skewed towards administrative requirements, this ethnographic study revealed opportunities for surgical providers to strike a better balance between clinical and administrative documentation needs. Future work will build on these findings to design and implement new routines that minimize the cognitive and time burdens of documentation in ACS settings.