Reduce EHR documentation time in your independent practice and improve patient care

Electronic health record (EHR) and electronic medical record (EMR) software enables healthcare providers to securely manage patient health information, streamline prescriptions, and enhance clinical workflows. Research confirms these systems help improve care outcomes.

Despite these advantages, independent practices increasingly struggle with EHR documentation burden. Time spent navigating complex systems reduces patient interaction, contributing to provider burnout and revenue decline.

This article outlines practical strategies for independent practices to minimize EHR/EMR documentation time while maximizing efficiency and patient care quality.

EHR documentation refers to the process of digitally recording patient health information, including medical history, diagnoses, treatments, and prescriptions, within an EHR.

This digital documentation replaces traditional paper charts and notes, and allows different healthcare providers and organizations to easily share, update, and analyze patient data. It's meant to make practice workflows more efficient. But it's not always successful at doing so.

In a Tebra survey about patient interaction time, providers reported that, for every patient visit, they spend an average of 9 minutes charting notes in their EHR software and 18 minutes on direct patient interaction. Below, we'll cover:

Why does it take so long to chart notes? A few factors significantly influence the EHR documentation burden for clinicians:

These and other factors can have serious consequences for patients and providers alike. EHR systems are still essential to running a successful practice. However, if implemented poorly, they take time away from patient care and can hurt outcomes.

Clinicians spending less time alone with patients is enough to negatively affect healthcare outcomes and satisfaction. So how can clinicians and staff in an independent practice reduce EHR documentation burden?

On average, providers spend approximately 9 minutes on charting notes for each patient. Here's how it breaks down by specialty:

When it comes to time with patients, providers reported spending an average of 21 minutes with new patients and an average of 15 minutes with returning ones. This means that for every hour providers spend with patients, they spend about 30 minutes on EHR documentation. This can have an enormous impact on individual clinicians, on the practice as a whole, and on patient care.

EHR/EMR documentation can create a challenging dilemma for healthcare providers. While legally required and essential for quality patient care (and protection against potential medical malpractice suits), excessive documentation directly reduces patient interaction time.

Tebra's survey reveals 72% of providers value patient interaction for job satisfaction, yet 82% experience burnout during appointments. EHR documentation demands, coupled with pressure to increase patient volume, intensify this burnout. 

The financial consequences are equally concerning. When clinicians take more time on EMR/EHR documentation than patient care, practices face inaccuracies, diminished trust, and higher patient turnover — all affecting your bottom line.

Properly implemented EHR systems can actually solve these challenges by streamlining workflows and eliminating redundancies. Understanding documentation pain points is essential to creating balance between thorough record-keeping and quality patient care.

While EHRs offer numerous benefits, they can also introduce new challenges, particularly when it comes to documentation. Independent practices often grapple with the time-consuming nature of EHR data entry, which can take away from patient care.

However, by implementing the right strategies and selecting the right EHR platform, you can improve efficiency and reduce the documentation burden.

Good documentation processes begin during the EHR system evaluation phase. Follow these tips to build your processes from the ground up, or improve your current ones:

While streamlining EHR/EMR workflows is critical, it's equally important to minimize errors in EHR documentation. Inaccurate or incomplete medical records can compromise patient safety, lead to billing issues, and even create legal challenges.

Implementing a clear process for correcting mistakes in the EHR while maintaining an audit trail is crucial for ensuring documentation integrity and accuracy. When clinicians or staff identify errors, they should fix them transparently, preserving the original entry and clearly marking the correction. This approach not only ensures the medical record remains complete but also makes it easier to prevent similar errors in the future.

Organizing documentation chronologically is equally important. Chronological order makes it easier to review and understanding the patient journey, and to quickly grasp the progression of care, treatments, and outcomes.

This sequential approach ensures that all members of the care team — including those in different healthcare organizations or facilities — can efficiently access and comprehend the most up-to-date information. This leads to better interoperability, more informed clinical decision-making, and stronger continuity of care.

Investing in comprehensive training and ongoing support is crucial for maximizing the benefits of your EHR system. A well-designed EHR should offer continuous learning opportunities to help both established and new providers navigate the ever-changing regulatory landscape. This education ensures that your team can fully leverage the system's full features to reduce documentation burden.

Additionally, exploring case studies of similar practices that have successfully increased their efficiency can provide valuable insights. These examples often reveal small, actionable tweaks that your practice can implement to streamline back-office processes and improve overall documentation workflows.

While legacy EHR software typically relies on manual processes for data entry, appointments, charting, and billing, modern health information technology solutions like Tebra’s EHR streamline workflows through automation, alerts, and integrations. These features make the entire system faster and easier to navigate.

Modern EHR systems like Tebra's provides customized template options to accelerate chart creation and note-taking. It may also include automatic transcription features to quickly summarize patient queries.

Furthermore, modern EHR systems integrate seamlessly with other aspects of your practice, such as scheduling calendars and appointment reminders, enhancing your overall operational efficiency. 

While security measures are essential for protecting patient data, they can sometimes add complexity to the documentation process. Following strict security protocols protects patient information and maintains compliance.

When documenting in an EHR, complying with the Health Insurance Portability and Accountability Act (HIPAA) and keeping protected health information (PHI) secure is crucial.

This involves implementing robust technological safeguards, such as:

Physical safeguards, like secure server rooms and controlled access to workstations and mobile devices, are also important.

Complex security processes, while essential for protecting patient data, can slow down workflows and add complexity to the documentation process. The challenge lies in achieving robust security with usability to minimize the burden on clinicians. A modern, robust EHR system should help your practice balance both.

Reducing the EHR documentation burden is an ongoing process that requires constant attention and refinement. While implementing the strategies above can lead to significant improvements, it's vital to establish a culture of continual improvement within your practice.

This approach involves regularly assessing your documentation workflows, gathering feedback from clinicians and staff, and staying informed about new EHR features and best practices. By doing so, you can adapt to changing regulations, technological advancements, and practice needs. This will ensure that your EHR documentation processes remain as efficient and effective as possible over time.

Tebra’s 2024 survey on patient interaction time highlights current challenges providers face regarding charting documentation and building patient relationships.

By prioritizing user-friendly EHR systems, optimizing workflows, and investing in ongoing training and support, independent practices can overcome documentation challenges, reduce administrative burden, and ultimately dedicate more time to what matters most: providing exceptional patient care.