G. J. Eckenrode1, H. Yeo1 1Weill Cornell Medical College,Surgery,New York, NY, USA
Introduction:
Time spent on clinical documentation is frequently cited as a contributing factor in physician burnout. Many physicians believe that the amount of patient documentation, both in terms of number of documents required as well as total length of documents, is increasing and has created a significant burden. There is a paucity evidence regarding the actual volume of increase and the amount of documentation taking place.
Methods:
We used a database of text-based clinical documents extracted from the inpatient electronic medical record (EMR) of a single institution. This database was established in 2014 and aggregates all electronic medical information for all patients treated by a large gastrointestinal surgery center within the institution. It contains notes dating from the widespread adoption of electronic medical documentation in approximately 2006 to the present day. We extracted all physician-visible text-based notes for each patient’s entire hospital stay for analysis. The number of notes and the word count for each note was calculated for each patient for each day.
Results:
The database contains 141,480 unique patient identification numbers and 10,925,542 physician-visible inpatient notes. Notes prior to 2007 were excluded due to low daily volume reflective of low document capture by the database. We found 1,591 note types as labeled by the EMR. The range of patients receiving notes on any given day ranged from 250 – 350 patients in 2007 with a steady increase to 400 – 1100 patients at the end of 2017. The average number of notes per patient was 77 with a range of 1 – 10,000. The average number of notes per patient per day remained constant over time, with a range of 4-6 but the number of words per patient per day rose constantly with time from 4,000 – 6,000 in 2008 to 12,000 – 14,000 per day at the end of 2017, a 3-fold increase.
Conclusion:
While the number of notes per patient per day has been constant over time, the number of words per note have increased markedly. Over the past decade, at this single institution patient documentation has increased in both quantity and complexity, requiring more work from physicians to create and manage, increasing the burden of clinical care.
