Optimized EHR flowsheets found to reduce clinician burden, burnout

By | March 16, 2021

Documentation burden is a common problem with modern electronic health record systems. EHRs have been linked to many benefits, from improving care quality and reducing prescription errors to facilitating biomedical research. But documentation burden is contributing to clinician burnout. 

While a number of solutions have been proposed, most – such as voice recorders and motion sensors – are in the prototype phase. In the short term, simplifying and improving flowsheet functionality may be the best means of addressing the issue.

That’s the main finding of “Contribution of Free-Text Comments to the Burden of Documentation: Assessment and Analysis of Vital Sign Comments in Flowsheets,” published this month in the Journal of Medical Internet Research.

Flowsheets are standardized tools in EHR systems that are helpful in documenting longitudinal patient information – such as assessments, observations and routine care – in a grid-type format. In each flowsheet entry, a healthcare provider can enter values into a cell from provided lists or types in numerical values such as blood pressure or temperature. 

By default, the comments (if there are any) are hidden behind an icon within the flowsheet entry. Providers can review a comment by clicking or hovering over the icon to open the comment display dialog. Although the flowsheet comments are optional, some clinicians find them useful and make an extra effort to provide them. 

Yet comments may introduce a documentation burden stemming from limitations in the existing EHR functionality, the data showed. Given that flowsheet comments are made accessible in a manner that’s not always obvious, their content can be leveraged to design more effective strategies for efficiently recording them.


Documentation burden arises from various factors, such as the complex functionalities of EHR systems, increase in the amount of data being collected and the challenge of prioritizing the information scattered in different locations in an EHR system.

The U.S. Department of Health and Human Services has released strategies to reduce the burden of using health information technology (and EHRs in particular), noting that the causes of documentation burden are many and complex, and must be addressed on several levels by EHR vendors, regulatory agencies, insurers and healthcare organizations themselves.

In particular, one of the proposed strategies is to simplify documentation requirements for evaluation and management by streamlining Medicare Physician Fee Schedule final rules.

In addition to those policy changes, alternative recording strategies could well make a dent in burnout levels and in the overall effect of EHR workflow burdens.

Authors evaluated 209,055 vital sign comments in flowsheets that were generated in the Epic EHR system at the Vanderbilt University Medical Center in 2018. They applied topic modeling, as well as the natural language processing Clinical Language Annotation, Modeling and Processing software system, to extract generally discussed topics and detailed medical terms to investigate the stories communicated in these comments.

The results showed that 63.33% of the users who entered vital signs made at least one free-text comment in vital sign flowsheet entries. The user roles that were most likely to compose comments were registered nurse, technician and licensed nurse. The most frequently identified topics were the notification of a result to healthcare providers, the context of a measurement and an inability to obtain a vital sign. 

There were 4,187 unique medical terms that were extracted from 46,029 comments, including many symptom-related terms such as “pain,” “upset,” “dizziness,” “coughing,” “anxiety,” “distress,” and “fever,” and drug-related terms such as “Tylenol,” “anesthesia,” “cannula,” “oxygen,” “Motrin,” “Rituxan,” and “Labetalol.”

Considering that flowsheet comments are generally not displayed or automatically pulled into any clinical notes, the findings suggest that the flowsheet comment functionality can be simplified – for example, via structured response fields instead of a text input dialog – to reduce provider effort.

Moreover, rich and clinically important medical terms such as medications and symptoms should be explicitly recorded in clinical notes for better visibility.


Hospitals have been overwhelmed and short-staffed as COVID-19 has ripped through many areas of the country, straining resources and stretching the workforce thin.

The pandemic is taking a toll on the mental and emotional wellbeing of physicians, with female physicians and those in critical care and infectious disease reporting the highest burnout rates during the public health emergency, according to findings from a December physician burnout report from Medscape.

Burnout and the stress of the pandemic – including factors such as personal risk, social distancing and financial uncertainty – appeared to diminish physicians’ overall work life happiness, with only 49% reporting they were happy in 2020, versus 69% pre-pandemic. More than one-third (34%) reported feeling unhappy last year, compared with 19% in 2019.

Nearly 80% of physicians said they felt burned out prior to the pandemic, but one in five said their burnout emerged only last year. Critical care (51%), rheumatology (50%) and infectious disease specialists (49%) ranked among the highest in reporting burnout for the first time since Medscape began surveying on the issue in 2013.

Even prior to the pandemic, burnout among healthcare professionals was a pervasive public health concern, with some studies reporting burnout for more than 50% of clinicians.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com

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