title: Electronic health records improve clinical note quality.
abstract: OBJECTIVE
  The clinical note documents the clinician's information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes.
  
  
  METHODS
  A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes.
  
  
  RESULTS
  The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval.
  
  
  CONCLUSIONS
  The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.
authors.affiliation: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Harry B
authors.initials: HB
authors.lastname: Burke
authors.affiliation: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Laura L
authors.initials: LL
authors.lastname: Sessums
authors.affiliation: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Albert
authors.initials: A
authors.lastname: Hoang
authors.affiliation: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Dorothy A
authors.initials: DA
authors.lastname: Becher
authors.affiliation: National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Fontelo
authors.affiliation: National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: Fang
authors.initials: F
authors.lastname: Liu
authors.affiliation: Department of Family, Medicine, Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Stephens
authors.affiliation: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Louis N
authors.initials: LN
authors.lastname: Pangaro
authors.affiliation: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Patrick G
authors.initials: PG
authors.lastname: O'Malley
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Nancy S
authors.initials: NS
authors.lastname: Baxi
authors.affiliation: Department of Family, Medicine, Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Bunt
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Vincent F
authors.initials: VF
authors.lastname: Capaldi
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Chen
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Cooper
authors.affiliation: Ft. Belvoir Community Hospital, Fort Belvoir, VA, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Djuric
authors.affiliation: Ft. Belvoir Community Hospital, Fort Belvoir, VA, USA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hodge
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Shawn
authors.initials: S
authors.lastname: Kane
authors.affiliation: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Magee
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Zizette R
authors.initials: ZR
authors.lastname: Makary
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Renee M
authors.initials: RM
authors.lastname: Mallory
authors.affiliation: Department of Family, Medicine, Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Miller
authors.affiliation: Department of Family, Medicine, Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Saperstein
authors.affiliation: Department of Family, Medicine, Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Servey
authors.affiliation: Department of Public Health Sciences, Clemson University, Clemson, SC, USA.
authors.forename: Ronald W
authors.initials: RW
authors.lastname: Gimbel
mesh_terms: D057286:Electronic Health Records; D006801:Humans; D008137:Longitudinal Studies; D008499:Medical Records / Q000592:standards*; D012189:Retrospective Studies
keywords: QNOTE; clinical note; clinical quality; electronic health record; note quality