Variation in Physicians’ Electronic Health Record Documentation and Potential Patient Harm from That Variation

Cohen, Genna R.; Friedman, Charles P.; Ryan, Andrew M.; Richardson, Caroline R.; Adler-Milstein, Julia

doi:10.1007/s11606-019-05025-3

Cited by 117Electronic Health Records SystemsMedical Coding and Health InformationNursing Diagnosis and Documentation

Variation in Physicians’ Electronic Health Record Documentation and Potential Patient Harm from That Variation

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Cohen, Genna R., Friedman, Charles P., Ryan, Andrew M., Richardson, Caroline R., Adler-Milstein, Julia·2019·Journal of General Internal Medicine

DOI 10.1007/s11606-019-05025-3PMC PMC6848521

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Abstract

Background Physician-to-physician variation in electronic health record (EHR) documentation not driven by patients' clinical status could be harmful. Objective Measure variation in completion of common clinical documentation domains. Identify perceived causes and effects of variation and strategies to mitigate negative effects. Design Sequential, explanatory, mixed methods using log data from a commercial EHR vendor and semi-structured interviews with outpatient primary care practices. Participants Quantitative: 170,332 encounters led by 809 physicians in 237 practices. Qualitative: 40 interviewees in 10 practices. Main measures Interquartile range (IQR) of the proportion of encounters in which a physician completed documentation, for each documentation category. Multilevel linear regression measured the proportion of variation at the physician level. Key results Five clinical documentation categories had substantial and statistically significant (p < 0.001) variation at the physician level after accounting for state, organization, and practice levels: (1) discussing results (IQR = 50.8%, proportion of variation explained by physician level = 78.1%); (2) assessment and diagnosis (IQR = 60.4%, physician-level variation = 76.0%); (3) problem list (IQR = 73.1%, physician-level variation = 70.1%); (4) review of systems (IQR = 62.3%, physician-level variation = 67.7%); and (5) social history (IQR = 53.3%, physician-level variation = 62.2%). Drivers of variation from interviews included user preferences and EHR designs with multiple places to record similar information. Variation was perceived to create documentation inefficiencies and risk patient harm due to missed or misinterpreted information. Mitigation strategies included targeted user training during EHR implementation and practice meetings focused on documentation standardization. Conclusions Physician-to-physician variation in EHR documentation impedes effective and safe use of EHRs, but there are potential strategies to mitigate negative consequences.

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Studies using raw audit logs fit into three broad categories: manual mapping, identification of networks, application of automatic methods.
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From Electronic health record activity changes around new decision support implementation: monitoring using audit logs and topic modeling (2025) · cites this paper as [76]
The Quantitative section describes this study’s use of EHR clickstream logs, and the Analytic Approach describes its own analysis. Neither section classifies studies using raw audit logs into three categories. Searches for the proposed categories and for a three-category classification found no such passage in our copy; page numbers were not available. (LLM, conf=0.76)
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Physician Practice Variation in Electronic Health Record Documentation.
Cohen, G. R. (2016) · Deep Blue (University of Michigan)
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Authors: Cohen, G. R., Friedman, C. P., Ryan, A. M., Richardson, C. R., & Adler-Milstein, J.
Affiliations: University of Michigan (US)
Michigan Medicine (US)
Corresponding author: Cohen, Genna R.
ORCID: Cohen, Genna R.
Friedman, Charles P.
Ryan, Andrew M.
Richardson, Caroline R.
Venue: Journal of General Internal Medicine
Publisher: Springer Science and Business Media LLC
Published: 2019-06-10
Volume: 34
Issue: 11
Pages: 2355-2367
ISSN: 0884-8734 (ISSN-L)
1525-1497
DOI: 10.1007/s11606-019-05025-3
PMC: PMC6848521
OpenAlex: W2950509749
Cited by: 117
References: 33
Citations by year: 2026: 20 · 2025: 18 · 2024: 12 · 2023: 21 · 2022: 18 · 2021: 16 · 2020: 9 · 2019: 3
FWCI: 12.55
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.springer.com/tdm (tdm)
www.springer.com/tdm (vor)
Locations: Journal of General Internal Medicine (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: University of Michigan
Agency for Healthcare Research and Quality (R36 HS023719)
Topics: Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
Keywords: electronic health record documentation, clinical documentation quality, patient harm, documentation standardization, EHR design, user preferences, problem list, review of systems, social history, assessment and diagnosis
MeSH terms: Adult, Aged, Aged, 80 and over, Clinical Competence, Documentation, Female, Humans, Male, Middle Aged, Physicians, Electronic Health Records, Patient Harm

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Variation in Physicians’ Electronic Health Record Documentation and Potential Patient Harm from That Variation

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