University of Missouri School of Medicine MU Health School of Medicine
NewsDivider

Nov. 3, 2015

Richelle Koopman

Richelle Koopman, MD, associate professor of family and community medicine at the MU School of Medicine, says it is time to redesign electronic health records to better meet the needs of physicians and to deliver the best care to patients.

Clinic Notes Should Be Re-Engineered to Meet Needs of Physicians

Better documentation tools can lead to more efficient, safer patient care

When physicians prepare for patient visits, one of their first steps is to review clinic notes or health records that recap their patients’ medical history. Since the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, approximately 78 percent of office-based physicians have adopted electronic health records (EHR). However, previous research found only 38 percent of physicians were highly satisfied with the system, and many believe the way a patient’s health information is displayed in EHRs reduces the efficiency and productivity of patient care.

Now, in a new study, University of Missouri researchers say it is time to redesign EHR documentation tools to better meet the needs of physicians in order to deliver the best care to patients.

“While EHRs have granted physicians access to more information than ever before, they also include lots of extraneous information that does not contribute to the care of the patient,” said Richelle Koopman, MD, associate professor of family and community medicine at the MU School of Medicine.

Koopman and her colleagues watched primary care physicians navigate through EHRs when preparing for patient visits and asked them to highlight what parts of the notes they found most and least important. Physicians overwhelmingly found the “assessment” and “plan” sections of clinic notes to be the most important and usually reviewed those first, while the “review of systems” section, which is required by Medicare and Medicaid for billing purposes, to be the least valuable information for patient care.

“Most physicians we observed skipped right to the assessment and plan sections, which include the diagnoses of the patient from the last visit and notes on how physicians planned to address the diagnoses,” Koopman said. “In addition, physicians expressed a lot of frustration about the poor utility of the ‘review of systems’ section and said it had little value in addressing patient care.”

During the transition from paper charts to EHRs, the system’s creators mimicked the look of the paper chart, which already was difficult to navigate because of increasing federal and regulatory demands on required information.

Koopman says early EHR documentation that mimicked the paper records led to a lot of redundant and cluttered information presented in an outdated fashion. She suggests patient information become more organized to allow physicians to spend more time with their patients instead of scrambling through notes to find the most valuable information.

In addition, Koopman says her research supports the need to change the information needed for medical billing because a more streamlined way of presenting medical information can reduce medical errors that compromise patient safety.

In upcoming research, Koopman will work with Jeff Belden, MD, professor of family and community medicine at the MU School of Medicine, to discover the best way to organize patient information in clinical notes by using eye-tracking software to see how quickly physicians can find information using different clinical note prototypes they created.

Thomas Selva, MD, chief medical information officer for MU Health Care, noted that the University of Missouri and the Tiger Institute for Health Innovation are national leaders in the development of better documentation tools.

According to Selva, numerous leading-edge tools that will facilitate the changes Koopman’s research called for will be implemented at MU Health Care this year.

Koopman’s study, “Physician Information Needs and Electronic Health Records: Time to Reengineer the Clinic Note,” was published by the Journal of the American Board of Family Medicine and was funded by Mizzou Advantage, an initiative that fosters interdisciplinary collaboration among faculty, staff, students and external partners to solve real-world problems.

Photos: Download a high-resolution photo of Richelle Koopman, MD.


Media Contacts

Media Relations
University of Missouri Health System
One Hospital Drive, DC028.00
Columbia, MO 65212
24/7 on-call pager: (573) 876-0708

Mary Jenkins
Public Relations Manager
Email
(573) 882-7299

Jennifer Coffman
Senior Strategic Communications Consultant
Email
(573) 884-4108

Diamond Dixon
Media Relations Coor.
Email
(573) 884-7541

Jeff Hoelscher
Media Relations Coor.
Email
(573) 884-1608

Derek Thompson
Media Relations Coor.
Email
(573) 882-3323

Justin Kelley
Media Producer (Photographer)
Email
(573) 882-5786
Pager: (573) 397-9289

Web Communications
University of Missouri Health System
One Hospital Drive, MA204G, DC018.00
Columbia, MO 65212
(573) 884-0298

Jennifer Orford
Communications Manager
Email
(573) 884-0298

Deidra Ashley
Strat. Comm. Associate
Email
(573) 884-3988

Jesslyn Chew
Senior Strategic Communications Consultant
Email
(573) 884-2891

Andrea Waner
Communications Specialist
Email
(573) 882-4173

Justin Willett
Senior Strategic Communications Consultant
Email
(573) 884-7740

MU Health Magazine

Latest News

News Archive
Printer Friendly
Follow us on Twitter!   Facebook   YouTube Videos   Instagram   Pinterest  
Website created and maintained by the Office of Communications. Contact the MU School of Medicine.
Revised: December 03, 2015 - Copyright © 2014 - Curators of the University of Missouri. All rights reserved. DMCA and other copyright information. An equal opportunity/access/affirmative action/pro-disabled and veteran employer.