Fellows journal Club
Article: Jacob A, Raj R, Alagusundaramoorthy S, Wei J, Wu J, Eng M. Impact of Patient Load on the Quality of Electronic Medical Record Documentation. Journal of Medical Education and Curricular Development. 2021;8:1-6.
Fellow: Kelli Martinez, MD; The University of Texas at Austin Dell Medical School, Dell Children’s Medical Center
Summary: The introduction of Electronic Medical Records (EMR) has become a significant part of physicians’ daily routine as well as an important communication tool between providers. Unfortunately, inaccurate and misleading information can potentially lead to adverse patient outcomes. Studies have shown that EMR figures in the top reasons for physician burnout. The ACGME requires residency programs to ensure first-year internal medicine residents are not responsible for more than 10 patients at a time to reduce burnout and improve patient care. This is a randomly assigned number and the implications have not been assessed especially with regards to the technology-in-medicine.
This is a double blind, single-center, retrospective observational study done at a community teaching hospital. Documentation was assessed using the Responsible Electronic Documentation (RED) Checklist, a validated scoring tool to assess quality and accuracy of progress notes. Investigators selected and scored a total of 80 notes from different patients. The authors calculated scores and compared it to the resident’s call status and the number of patients being seen that day to evaluate how patient load affected documentation quality. For each resident, a one-way analysis of variance (ANOVA) was employed to compare the scores across the 4 call days of measurement.
The residents took care of a mean of 4 patients on a “call” day, 9.2 patients on a “post-call” day, 7.2 patients on a “mid-call” day, and 5.5 patients on a “pre-call” day. The mean checklist score was 68.1%, 57%, 68.6%, and 72.1% on call, post-call, mid-call, and pre-call days respectively. The lowest scoring sections were updated impressions of study reports and exam being different from the previous day. The largest difference was noted between “mid-call” and “post-call” days. There was a negative correlation between progress note scores and the number of patients per resident on the day of documentation. The authors speculate that multipronged education along with reduction of patient workload during early months of training are needed to ensure residents are adequately trained on EMR.
Strengths: Prior research has shown effectiveness of some interventions like resident education, paper or electronic templates, and feedback help in overall quality and accuracy of physician documentation. This is the first study to show the negative effect of resident’s workload on the quality of documentation.
Limitations: This study was a single center, retrospective study. A multicenter study would better validate these findings. This could extend data to include residents on overnight shifts or 24 hour shifts. It was unclear what kind and amount of education residents received on EMR documentation prior to starting residency. In addition, the authors could not directly identify the effect of post-call fatigue and burn out on the quality of resident documentation although it was presumed.
Major Takeaway: The quality of documentation by medical residents is significantly impacted by resident workload. More studies are needed to determine an appropriate patient workload for residents as well as optimal training of residents.
How this article should impact our practice: Prior versions of the ACGME program requirements for pediatrics listed a minimum and maximum patient load for inpatient rotations; however, this has been removed. Each pediatric residency program has their own “patient cap” rules for their institution. An optimal number of patients has not been identified to provide an ideal educational experience and optimal patient safety while preserving accuracy of documentation and limiting burn out in residents. Our institution recently formalized education for documentation for first year residents. Preliminary data shows an improvement in progress note quality when using a modified RED checklist. Medical education leadership should consider providing similar education to incoming residents in addition to exploring an optimal patient load for their institution.
Fellow: Kelli Martinez, MD; The University of Texas at Austin Dell Medical School, Dell Children’s Medical Center
Summary: The introduction of Electronic Medical Records (EMR) has become a significant part of physicians’ daily routine as well as an important communication tool between providers. Unfortunately, inaccurate and misleading information can potentially lead to adverse patient outcomes. Studies have shown that EMR figures in the top reasons for physician burnout. The ACGME requires residency programs to ensure first-year internal medicine residents are not responsible for more than 10 patients at a time to reduce burnout and improve patient care. This is a randomly assigned number and the implications have not been assessed especially with regards to the technology-in-medicine.
This is a double blind, single-center, retrospective observational study done at a community teaching hospital. Documentation was assessed using the Responsible Electronic Documentation (RED) Checklist, a validated scoring tool to assess quality and accuracy of progress notes. Investigators selected and scored a total of 80 notes from different patients. The authors calculated scores and compared it to the resident’s call status and the number of patients being seen that day to evaluate how patient load affected documentation quality. For each resident, a one-way analysis of variance (ANOVA) was employed to compare the scores across the 4 call days of measurement.
The residents took care of a mean of 4 patients on a “call” day, 9.2 patients on a “post-call” day, 7.2 patients on a “mid-call” day, and 5.5 patients on a “pre-call” day. The mean checklist score was 68.1%, 57%, 68.6%, and 72.1% on call, post-call, mid-call, and pre-call days respectively. The lowest scoring sections were updated impressions of study reports and exam being different from the previous day. The largest difference was noted between “mid-call” and “post-call” days. There was a negative correlation between progress note scores and the number of patients per resident on the day of documentation. The authors speculate that multipronged education along with reduction of patient workload during early months of training are needed to ensure residents are adequately trained on EMR.
Strengths: Prior research has shown effectiveness of some interventions like resident education, paper or electronic templates, and feedback help in overall quality and accuracy of physician documentation. This is the first study to show the negative effect of resident’s workload on the quality of documentation.
Limitations: This study was a single center, retrospective study. A multicenter study would better validate these findings. This could extend data to include residents on overnight shifts or 24 hour shifts. It was unclear what kind and amount of education residents received on EMR documentation prior to starting residency. In addition, the authors could not directly identify the effect of post-call fatigue and burn out on the quality of resident documentation although it was presumed.
Major Takeaway: The quality of documentation by medical residents is significantly impacted by resident workload. More studies are needed to determine an appropriate patient workload for residents as well as optimal training of residents.
How this article should impact our practice: Prior versions of the ACGME program requirements for pediatrics listed a minimum and maximum patient load for inpatient rotations; however, this has been removed. Each pediatric residency program has their own “patient cap” rules for their institution. An optimal number of patients has not been identified to provide an ideal educational experience and optimal patient safety while preserving accuracy of documentation and limiting burn out in residents. Our institution recently formalized education for documentation for first year residents. Preliminary data shows an improvement in progress note quality when using a modified RED checklist. Medical education leadership should consider providing similar education to incoming residents in addition to exploring an optimal patient load for their institution.
Fellow: Kelli Martinez, MD, 2nd year PHM fellow, The University of Texas at Austin Dell Medical School, Dell Children’s Medical Center
Current Research: Throughout fellowship, Kelli’s has also completed the Dell Medical School Fellowship in Medical Education. Her research is focused on goal oriented feedback and curriculum development. Her work has been accepted as a workshop to be presented at the Pediatric Hospital Medicine Conference in 2021 and the Dell Med Research Symposium. She is also the author of a book chapter that is pending publication in April 2022.
Future Plans: After completion of fellowship, Kelli hopes to work as a Pediatric Hospitalist in an academic center with continued involvement in medical education and hospital leadership.
Fun Fact: Kelli enjoys running and spending time with her family. Her 3rd year of medical school she ran 12 half marathons and one full marathon. She has 3 sisters, 1 nephew, 1 niece on the way, and is excited to get married in the spring.
Current Research: Throughout fellowship, Kelli’s has also completed the Dell Medical School Fellowship in Medical Education. Her research is focused on goal oriented feedback and curriculum development. Her work has been accepted as a workshop to be presented at the Pediatric Hospital Medicine Conference in 2021 and the Dell Med Research Symposium. She is also the author of a book chapter that is pending publication in April 2022.
Future Plans: After completion of fellowship, Kelli hopes to work as a Pediatric Hospitalist in an academic center with continued involvement in medical education and hospital leadership.
Fun Fact: Kelli enjoys running and spending time with her family. Her 3rd year of medical school she ran 12 half marathons and one full marathon. She has 3 sisters, 1 nephew, 1 niece on the way, and is excited to get married in the spring.
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