Model to improve charting performance for physicians

Maryna Mammoliti, MD, Adam Ly, MScOT, and Cindy Chen, BSc

Timely, accessible, and comprehensive charting of medical care is a complex issue that has clinical, legal, regulatory, and financial implications. Documentation, along with the rise in other administrative tasks, is a factor contributing to physician burnout. We posit that difficulties with charting are multifactorial and can stem from physician, patient, and environmental factors. Physician leaders have a responsibility to enforce charting standards and deadlines and are best positioned to lead charting-related solutions. To assist physician leaders, we propose a charting performance model as a tool to assess charting difficulties within their organizations.

KEYWORDS: physician health, charting, documentation, workplace health, leadership

Mammoliti M, Ly A, Chen C. Model to improve charting performance for physicians. Can J Physician Leadersh 2022;8(3):103-107

https://doi.org/10.37964/cr24757

Charting — the bane of our existence?

The documentation of medical care is required by medical boards and regulatory bodies to ensure continuity of care, quality improvement, and service reimbursement. Despite general guidelines, the format and details may vary among physician practice areas and institutions, even within specialties. Different institutions and regulatory bodies may set a mandatory timeline for documentation. For instance, in Ontario, the most responsible physician must complete a discharge summary for all inpatients within 48 hours of discharge.1 From a medicolegal perspective, documentation of the events of a medical visit or procedure can be used as evidence in criminal and civil lawsuits.2

A medical leader may be alerted by the records department about outstanding documentation or a physician with repeat documentation deficiencies. Physician leaders may be more involved than ever before in issues related to outstanding documentation because of the ease of tracking deficiencies with the implementation of electronic medical records (EMRs). Penalties for delayed charting can include, but are not limited to, informal performance management, suspension of hospital privileges, restrictions of a medical license, job loss, and lawsuits.

Physicians now spend about two hours on documentation for every hour they devote to patient care,3,4 and an average of 16 minutes is spent on the EMR for each patient encounter.5 This means that physicians spend an average of 5.9 hours of an 11.4-hour workday on the EMR, and 1.4 hours after clinic hours.6

Resident physicians also struggle with charting. One study found that first-year residents spent an average of 112 hours a month charting 206 patient encounters. Although these residents became more efficient over time, the number of hours continued to be significant, as it merely decreased from 7 to 5 hours a day over a 6-month period.7

Burnout has been defined as an occupational and workplace issue by the World Health Organization.8 Burnout refers specifically to phenomena in the occupational context. In 2017, 43.9% of physicians in the United States were suffering from this syndrome.9-10 Clerical tasks, such as charting, are predictors of physician stress leading to burnout.11 Administrative obligations, including charting, were ranked second among the top 10 burnout contributors by the Ontario Medical Association’s Burnout Task Force in 2021.12 Streamlining and reducing documentation and administrative work ranked number 1 in its top 10 solutions to physician burnout.

Physicians who did not have time for EMR documentation were 2.8 times more likely to show symptoms of burnout than those who reported having sufficient time.13 Physicians who spent moderately high or excessive amounts of time on their EMR at home were 1.9 times more likely to show burnout symptoms than those who spent minimal or no time on the EMR at home. Physicians who agreed that EMRs add to the frustration of the day were 2.4 times more likely to show burnout symptoms than those who disagreed.

A survey of 25,018 physicians in the United States14 found that physicians doing ≥ 6 hours a week of charting after hours were twice as likely to report higher burnout scores compared with those charting ≤ 5 hours. The same study also found that physicians who believed that their organizations had done a great job in implementing, training, and supporting the EMR system were half as likely to report higher scores of burnout compared with those who disagreed.

In this article, we propose a charting performance model (CPM) as a tool for physician leaders to assess and apply interventions to various domains affecting charting performance, thereby potentially mitigating one factor that can contribute to physician burnout.

The charting performance model

In developing our model in the context of charting, we applied fundamental theories and models used in occupational therapy. The Canadian Model of Occupational Performance and Engagement (CMOP-E) theorizes that a person’s ability to perform their life’s occupations depends on the interplay between the person and their environment.15

In our CPM (Figure 1), charting performance depends in part on the physician’s characteristics in the areas of mental health, physical and cognitive abilities, skills in using the EMR, and traits, such as perfectionism. Environmental factors, such as physical, social, institutional, and cultural aspects, also play a role. We extend the scope of the environment by adding technology. In further expanding the CMOP-E, we add patient factors, including patient complexity, the patient–physician relationship, and urgency. We further propose applying interventions to each domain to optimize occupational performance in the realm of charting.16

Physician factors

1-Mental health — Untreated or unrecognized mental health conditions, such as depression, attention deficit hyperactivity disorder, substance use, or anxiety, can impact one’s ability to chart. For example, depressive symptoms can contribute to poor concentration and cognitive slowing. Anxiety can cause physicians to be preoccupied, delaying chart completion. Even without a psychiatric diagnosis, emotions (e.g., fear, guilt, or stress) may impact charting behaviour. Understanding mental health in the workplace and redirecting to the appropriate medical care can help. Coaching and therapy in this area may also be helpful.

2-Physical abilities — Physical states can include fatigue, hunger, pain, and various medical conditions, such as poorly controlled diabetes, migraines, and chronic pain. These states may impair physical functioning and can further impact emotional and cognitive states, thus distracting from charting. Support from leaders to treat or accommodate the medical condition itself may help improve charting

3-Cognitive abilities — Charting requires cognitive functions, such as working memory, concentration, and prioritizing. Some of these functions may decrease with age, distraction, or medical conditions. Appropriate workplace accommodations, such as a quiet or private space may be helpful.

4-Skills — Skills such as time management, organization, and technological skills develop through prior life experiences and/or on-the-job. One study17 of physicians completing a physician enhancement program consisted of a monthly chart audit, telephone follow-up with a faculty monitor, and regular practice visits. It found that participants significantly improved their charting skills and maintained them 24 months later. The EMR has become a presence in many facilities, yet physician skill level and understanding of the full EMR potential may be lagging. Instruction in the use of shortcuts, smart phrases, and templates may be helpful.

5-Perfectionism — Perfectionism is a common attribute of physicians.18-21 This quality can extend into writing the “perfect” chart note. Although perfectionism can be useful in other elements of training and practice, unhealthy perfectionism can lengthen charting time. Standards for charting should be made clear. These may be less rigorous than other types of documentation and may include point form, lists, and pre-populated information to ease the burden of perfectionism.

Environmental factors

1-Physical — The physical environment refers to the natural and built world around us.22 The design of a building may cause distracting environments for physicians. For example, if charting is completed in a shared space without the ability to close a door or use dividers between computers, visual and noise stimuli can be a distraction. Open-concept spaces can invite interruption from other team members. A clinic may also be physically disorganized, which decreases workflow efficiency. Therefore, strategies such as providing distraction-free spaces, improving the workflow organization to save time, and using “do not disturb” signs can be helpful.

2-Social — The social environment refers to the people, organization, and society, and our relationships with them.16 In a clinical setting, this includes the team of physicians, patients, nurses, medical learners, and administrative staff. Unreasonable workloads, unnecessary emails, communication issues, and boundary conflicts among the team can take time away from charting. Therefore, strategies such as defining the roles and responsibilities of each team member, delegation of tasks, and a “buddy system” for charting can be helpful.

3-Institutional — The institutional environment refers to policies, funding, regulations, and laws that govern an organization or society.15 Institutional factors can have a significant impact on charting performance. For example, current funding models for particular specialties may force physicians to see more patients in less time to pay for overhead. Inadequate scheduled time, lack of training in using the EMR system, and lack of efficient templates can increase charting time. Therefore, strategies such as flexibility to work from home, scheduled time for administration and charting, funding for scribes, and a charting mentorship program can be helpful.

4-Cultural — In the context of charting, we refer to the cultural environment as the organizational and medical culture. A work culture that focuses on unreasonable productivity, lack of boundaries, and perfection can impact charting time. Leaders who promote a culture of work–life balance and provide support rather than punitive measures when mistakes are made can enhance performance.

5-Technological — Given the rapidly changing advances in information and medical technology, the technological environment evolves faster than physicians can keep up. One survey3 found that excessive data entry requirements, “note bloat” (unnecessarily long cut-and-pasted progress notes), inaccessible information from other institutions, and notes geared toward billing rather than patient care were unhelpful factors in EMR design and use. On the other hand, participants found that the ability to message colleagues electronically, access the EMR from home, and share results with patients were helpful features.

Patient factors

1-Complexity of medical issues — Patients with more complex medical conditions and psychosocial needs require involvement of multiple specialties and services and may have specific follow-up needs. Thus, documentation of several conditions at the same visit may be difficult and tedious.

2-Patient–physician relationship — The patient–physician relationship can impact the documentation. For instance, if a physician feels threatened by the patient or family, they could gravitate toward defensive and detailed documentation, resulting in longer charting times.

3-Urgencies of patient care — Patient urgencies can interrupt workflow and add to the administrative burden that may arise from documenting unscheduled services. Providing protected time for documentation may help to ensure timely completion.

Conclusion

Charting is a required activity for patient care, legal and regulatory obligations, and remuneration. The demands of charting may contribute to higher levels of burnout. Using the CPM as a framework, physician leaders can take a systematic approach to assess charting issues of physicians in their organization and implement practical solutions. Further research is required to test the efficacy of the suggested interventions.

References

1.Transitions in care. Toronto: College of Physicians and Surgeons of Ontario; 2019. Available: https://tinyurl.com/585p2ea7

2.Medico-legal handbook for physicians in Canada. Ottawa: Canadian Medical Protective Association; 2021. Available: https://tinyurl.com/msadeu6k

3.Kroth PJ, Morioka-Douglas N, Veres S, Babbott S, Poplau S, Qeadan F, et al. Association of electronic health record design and use factors with clinician stress and burnout. JAMA Netw Open 2019;2(8):e199609. https://doi.org/10.1001/jamanetworkopen.2019.9609

4.Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016;165(11):753-60. https://doi.org/10.7326/M16-0961

5.Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc 2020;27(4):531-8. https://doi.org/10.1093/jamia/ocz220

6.Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan WJ, Sinsky CA, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017;15(5):419-26. https://doi.org/10.1370/afm.2121

7.Chen L, Guo U, Illipparambil LC, Netherton MD, Sheshadri B, Karu E, et al. Racing against the clock: internal medicine residents’ time spent on electronic health records. J Grad Med Educ 2016;8(1):39-44. https://doi.org/10.4300/JGME-D-15-00240.1

8.Burnout an “occupational phenomenon”: International Classification of Diseases. Geneva: World Health Organization; 2019. Available: https://tinyurl.com/mvjmfhes

9.Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work–life balance among US physicians relative to the general US Population. Arch Intern Med 2012;172(18):1377-85. https://doi.org/10.1001/archinternmed.2012.3199

10.Shanafelt TD, West CP, Sinsky C, Trockel M, Tutty M, Satele DV, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc 2019;94(9):1681-94. https://doi.org/10.1016/j.mayocp.2018.10.023

11.Tran B, Lenhart A, Ross R, Dorr DA. Burnout and EHR use among academic primary care physicians with varied clinical workloads. AMIA Jt Summits Transl Sci Proc 2019;2019:136-44. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6568076/

12.Ontario Medical Association Burnout Task Force. Healing the healers: system-level solutions to physician burnout. Toronto: Ontario Medical Association; 2021. Available: https://tinyurl.com/2yaxuk2w

13.Gardner RL, Cooper E, Haskell J, Harris D, Poplau S, Kroth PJ, Linzer M. Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc 2019;26(2):106-14. https://doi.org/10.1093/jamia/ocy145

14.Eschenroeder HC, Manzione LC, Adler-Milstein J, Bice C., Cash R, Duda C, et al. Associations of physician burnout with organizational electronic health record support and after-hours charting. J Am Med Inform Assoc 2021;28(5):960-6. https://doi.org/10.1093/jamia/ocab053

15.Townsend EA, Polatajko HJ. Enabling occupation II: advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa: Canadian Association of Occupational Therapists; 2013.

16.Law M, Cooper BA, Strong S, Stewart D, Rigby P, Letts L. The person-environment-occupation model: a transactive approach to occupational performance. Can J Occup Ther 1996;63:9-23. https://doi.org/10.1177/000841749606300103

17.Wenghofer E, Boal P, Floyd N, Lee J, Woodard R, Norcross W. Improving charting skills of physicians in monitored practice. J Contin Educ Health Prof 2018;38(4):244-9. https://doi.org/10.1097/CEH.0000000000000221

18.Martin SR, Heyming TW, Piroutek M, Kain ZN. 68 pediatric emergency physician burnout during the COVID-19 pandemic: the effect of perfectionism. Ann Emerg Med 2021;78(2):S33. https://doi.org/10.1016/j.annemergmed.2021.07.070

19.Shelley BP. Understanding physician burnout syndrome: antithesis of physician well-being. Arch Med Health Sci 2019;7(1):1-10. https://doi.org/10.4103/amhs.amhs_75_19

20.Rosenstein AH. Physician stress and burnout: taking care of yourself. Phys Exec 2012;38(6):22+.

21.Peters M. Perfectionism in doctors. BMJ 2012;344. https://doi.org/10.1136/bmj.e1674

22.Hamilton TB. Occupations and places. In Christiansen CH, Townsend EA. Introduction to occupation: the art and science of living. New Jersey: Prentice Hall; 2004. pp. 173-96.

Authors

Maryna Mammoliti, MD, FRCPC, is an adjunct professor at Western University, a locum psychiatrist at the Centre for Addiction and Mental Health, and a community psychiatrist.

Adam Ly, MScOT, is a registered occupational therapist at an outpatient health clinic in London, Ontario. He is also an adjunct lecturer at the School of Occupational Therapy, Western University, London, Ontario.

Cindy Chen, BSc, MD candidate, is a fourth-year medical student at the Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario.

Sponsorship and funding: Dr. Mammoliti is paid through OHIP, hospital stipends, speaking engagements on physician health and wellness topics, and independent medical evaluations and assessments. Adam Ly is employed by CBI Health Group and has received honoraria from Takeda. Cindy Chen has no conflicts of interest to declare.

Author attestation: All authors contributed equally to the development of this article using their clinical knowledge, experience, and review of each other’s work. MM led the recognition of charting performance issues among physicians and physician health; AL and MM led the theoretical framework of the model for improving charting performance and potential solutions, and CC took the lead in overall style and editing.

Correspondence to:

marynamammoliti@gmail.com

This article has been peer reviewed.