Reduce EHR documentation time in your independent practice and improve patient care

Electronic health record (EHR) software offers healthcare providers a convenient and compliant way to secure patient notes, prescribe medications, order labs, and make care delivery decisions. Studies, such as in the nursing journal SEANR or the Western Journal of Nursing Research, highlight that these programs can increase efficiency. They can also reduce medication errors and boost patient satisfaction. While EHR software offers undeniable benefits, independent practices face a growing challenge: the increasing burden of EHR documentation.

The time providers spend navigating complex systems and inputting data can significantly detract from valuable patient interaction time. This can lead to burnout, decreased patient satisfaction, and even lowered practice revenue. This article explores the extent of this challenge and provides actionable strategies for independent practices to reduce EHR/EMR documentation time, improve efficiency, and ultimately enhance patient care.

EHR documentation refers to the process of digitally recording patient information, including medical history, diagnoses, treatments, and prescriptions, within an EHR. This digital documentation replaces traditional paper charts and notes, and allows different healthcare providers and organizations to easily share, update, and analyze patient data. It's meant to make practice workflows more efficient. But it's not always successful at doing so.

In a Tebra survey about patient interaction time, providers reported that, for every patient visit, they spend an average of 9 minutes charting notes in their EHR software and 18 minutes on direct patient interaction. Below, we'll cover:

Why does it take so long to chart notes? A few factors significantly influence the EHR documentation burden for clinicians:

These and other factors can have serious consequences for patients and providers alike. EHR systems are still essential to running a successful practice. However, if implemented poorly, they take time away from patient care and can hurt outcomes. Clinicians spending less time alone with patients is enough to negatively affect healthcare outcomes and satisfaction. So how can clinicians and staff in an independent practice reduce EHR documentation burden?

On average, providers spend approximately 9 minutes on charting notes for each patient. Here's how it breaks down by specialty:

When it comes to time with patients, providers reported spending an average of 21 minutes with new patients and an average of 15 minutes with returning ones. This means that for every hour providers spend with patients, they spend about 30 minutes on EHR documentation. This can have an enormous impact on individual clinicians, on the practice as a whole, and on patient care.

Extensive EHR/EMR documentation significantly impacts patient interaction time, creating a challenging dilemma for healthcare providers. Documentation is mandatory and can't be eliminated; among other reasons, it's a legal requirement. Detailed notes are essential for optimal patient care and protection against potential medical malpractice suits. However, as the time devoted to charting notes increases, it invariably means less face-to-face time with patients.

Having less patient interaction time leads to significant consequences. It limits your ability to build strong relationships with them. It also increases the likelihood of appointment overruns, especially since patient questions are a top cause of delays. The ripple effect of overbooked or delayed appointments can lead to frustrated patients, stressed providers, and diminished revenue flow.

The meticulous nature of EHR documentation significantly contributes to provider workload and burnout. In Tebra’s survey, 72% of respondents said that patient interaction time impacts their job satisfaction, yet 82% reported feeling more burnt out during patient appointments. EHR documentation is a key factor in this burnout, exacerbated by the increasing pressure to see more patients daily. 

Plus, poor and inadequate EMR/EHR documentation has substantial financial implications. The hidden costs can dramatically affect your bottom line. When clinicians spend more time on paperwork than patient care, it can lead to inaccuracies, miscommunication, and the erosion of patient trust. As a result, independent practices may experience high patient turnover, impacting your financial stability. 

Interestingly, EHR documentation can address these issues if implemented correctly. Efficient EHR systems can streamline workflows, reduce redundancies, and ultimately save time. But before we explore solutions, it's important to understand how EHR documentation burdens can inadvertently increase rather than reduce clinician workloads. By identifying these pain points, we can develop a more balanced approach to patient care and documentation.

While EHRs offer numerous benefits, they can also introduce new challenges, particularly when it comes to documentation. Independent practices often grapple with the time-consuming nature of EHR data entry, which can take away from patient care. However, by implementing the right strategies and selecting the right EHR platform, you can improve efficiency and reduce the documentation burden.

Good documentation processes begin during the EHR system evaluation phase. Complex and challenging EHR software can significantly slow down documentation. Prioritize a user-friendly interface and intuitive design. Look for customization options that align documentation workflows with your needs without sacrificing compliance. Be wary of common issues like option overload, complex EHR workflows, and poor carry forward options, which all contribute to a higher documentation burden.

While streamlining EHR/EMR workflows is critical, it's equally important to minimize errors in EHR documentation. Inaccurate or incomplete records can compromise patient safety, lead to billing issues, and even create legal challenges.

Implementing a clear process for correcting mistakes in the EHR while maintaining an audit trail is crucial for ensuring documentation integrity and accuracy. When clinicians or staff identify errors, they should fix them transparently, preserving the original entry and clearly marking the correction. This approach not only ensures the record remains complete but also makes it easier to prevent similar errors in the future.

Organizing documentation chronologically is equally important. Chronological order makes it easier to review and understanding the patient journey, and to quickly grasp the progression of care, treatments, and outcomes. This sequential approach ensures that all members of the care team — including those in different healthcare organizations or facilities — can efficiently access and comprehend the most up-to-date information. This leads to better interoperability, more informed decision-making, and stronger continuity of care.

Investing in comprehensive training and ongoing support is crucial for maximizing the benefits of your EHR system. It’s essential to invest in training and support. A well-designed EHR should offer continuous learning opportunities to help both established and new providers navigate the ever-changing regulatory landscape. This education ensures that your team can fully leverage the system's full features to reduce EHR documentation burden.

Additionally, exploring case studies of similar practices that have successfully increased their efficiency can provide valuable insights. These examples often reveal small, actionable tweaks that your practice can implement to streamline back-office processes and improve overall EHR documentation workflows.

While legacy EHR software typically relies on manual processes for data entry, appointments, charting, and billing, modern solutions like Tebra’s EHR streamline workflows through automation, alerts, and integrations. These features make the entire system faster and easier to navigate.

Modern EHR systems like Tebra's provides customized template options to accelerate chart creation and note-taking. It may also include automatic transcription features to quickly summarize patient queries. Furthermore, modern EHR systems integrate seamlessly with other aspects of your practice, such as scheduling calendars and appointment reminders, enhancing your overall operational efficiency. 

While security measures are essential for protecting patient data, they can sometimes add complexity to the documentation process. Following strict security protocols protects patient information and maintains compliance. This involves implementing robust technological safeguards, including encryption, multi-factor authentication, and regular security audits. Physical safeguards, like secure server rooms and controlled access to workstations and mobile devices, are also important.

Complex authentication processes, restricted access controls, and detailed audit trails, while essential for protecting patient data, can slow down workflows and add complexity to the documentation process. The challenge lies in balancing robust security with usability to minimize the burden on clinicians. A modern, robust EHR system should help your practice maintain good security while still streamlining your EHR/EMR workflows.

Reducing the EHR documentation burden is an ongoing process that requires constant attention and refinement. While implementing the strategies above can lead to significant improvements, it's crucial to establish a culture of continual improvement within your practice. This approach involves regularly assessing your documentation workflows, gathering feedback from clinicians and staff, and staying informed about new EHR features and best practices. By doing so, you can adapt to changing regulations, technological advancements, and practice needs. This will ensure that your EHR documentation processes remain as efficient and effective as possible over time.

Tebra’s 2024 survey on patient interaction time highlights current challenges providers face regarding charting documentation and building patient relationships.

By prioritizing user-friendly EHR systems, optimizing workflows, and investing in ongoing training and support, independent practices can overcome documentation challenges, reduce administrative burden, and ultimately dedicate more time to what matters most: providing exceptional patient care.

Check out the full report and learn how to optimize your back-office processes and create a seamless patient experience.