Which EHR documentation style best suits the quality of care a physician performs? Research published online May 19 in the Journal of the American Medical Informatics Association suggests dictated EHR documentation appears to fare worse than structured and free text documentation.
Jeffrey A. Linder, PhD, division of general medicine and primary care at Brigham and Women’s Hospital in Boston, and colleagues conducted a retrospective analysis of visits by patients with coronary artery disease and diabetes to the Partners Primary Care Practice Based Research Network to measure the quality of care of physicians who used dictation, structured documentation, and free text EHR documentation styles.
The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after primary care visits from March to August 2007. During the research period, 7,000 coronary artery disease and diabetes patients made 18,569 visits to 234 primary care physicians of whom 9 percent predominantly dictated their notes, 29 percent predominantly used structured documentation and 62 percent predominantly typed free text notes.
Based on 188,554 notes, dictators dictated 67 percent of their notes on average, used structured documentation 4 percent of the time and used free text 32 percent of the time. Structured documenters dictated less than 1 percent of their notes, used structured documentation for 54 percent and used free text for 46 percent. Free text documenters dictated less than 1 percent of their notes, used structured documentation for 4 percent and used free text for 96 percent.
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