Study finds issues raised by patients not included in medical records at some Midwest VA clinics

A recent study found medical records in some U.S. Department of Veterans Affairs clinics didn’t include most issues that patients brought up during their appointments. The study focused on the electronic medical records created by a small group of primary care clinicians in VA clinics across the Midwest.

Researchers found that fewer than half of the issues that patients raised were included in the provider’s notes. Those notes play a key role in communication and decision-making within clinical settings.

Dr. Michael Weiner, a research health scientist with the Regenstrief Institute and the U.S. Department of Veterans Affairs, said one potential cause for those omissions may be clinicians trying to balance their own understanding with the patient’s concerns.

“The clinician is then in a position where attention is needed to everything, everything, so there's a need to prioritize what has to be addressed,” Weiner said.

The study also found nearly half of the notes referred to information or observations that could not be verified. Weiner said a likely factor in this is the use of templates in electronic medical records.

While the use of templates can sometimes improve the thoroughness of the notes, it can also result in false information being included in the record. This can lead to a variety of negative consequences with billing integrity.
 

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Weiner said the department is using the study to continue to find ways to improve care.

“One example is exploring the potential role for artificial intelligence to improve the capture of information, as well as the documentation of information during medical visits,” Weiner said.

Weiner said other potential solutions include team-based writing and using communication techniques that confirm patients and providers are on the same page.

This problem isn’t exclusive to VA clinics. Weiner said similar findings have been seen in other settings.

“The challenges of aligning documentation with medical encounters is essentially global,” Weiner said. “It's a global challenge. And so we need to collaborate across institutions to find the most effective solutions and then test them in our own environments to see what works and whether local context or other influences change those outcomes.”

Weiner said the VA hasn’t finished the process of evaluating its electronic medical record system — and it likely never will. He said this is a continuous learning process to keep improving care as more research and tools become available.
 

Abigail is our health reporter. Contact them at aruhman@wboi.org.