Most providers use EHR note templates, but these templates are rarely standardized. Instead, most clinicians develop templates that fit their personal documentation workflow. 

Templates are a valuable documentation tool, but what gets lost when they aren’t shared or standardized? And how should individuals and organizations navigate the tradeoffs between personalized and standardized note templates?

A recent study addressed these questions by studying two years of EHR notes at an Oregon academic health center. They found template use was “frequent but fragmented,” meaning most providers use EHR templates to complete notes, but just a fraction of those templates are ever used by more than one provider.

How do providers use EHR note templates?

Templates are now the dominant method of writing clinical notes. 

The latest research shows that providers use templates to document nearly 9 out of 10 outpatient visits (89.3%). Another study determined that 56% of all text in outpatient notes came from templates.

Note templates allow EHR users to quickly insert previously used text or other EHR data through customizable forms. These forms can be full-note templates or shorter blocks of text (like EHR macros).

Here’s how a recent study describes various ways providers use note templates: 

“A clinician might use a full-note template to insert section headers and patient data to structure their note and aid chart review, their scribe might use a short-phrase template during the visit to insert a diagnosis they have difficulty spelling, and the clinician later use an attestation template to add text certifying the scribe’s edits.”

Most clinicians use templates because they provide clear benefits, such as: 

  • Reduced documentation time
  • Enforced standards 
  • Easier chart review
  • Clinical decision support

But using templates as the primary clinical documentation method also poses challenges. The most common concern is that templates can cause a rushed clinician to include extraneous information in the chart (threatening note quality and patient safety). 

Providers can also waste a lot of effort creating unique templates for every scenario, especially if templates aren’t shared. Personalized templates also make it difficult for organizations to standardize care.

The template “fragmentation” problem

The latest published research concluded that “template use was remarkably fragmented.” The study found that providers used over 100,000 unique templates to conduct 2.5 million outpatient visits during two years. But only 17% of these templates were ever used by more than one person.

The authors put it like this:

“Individual template development can align documentation workflows with clinical workflows, but it may also duplicate effort and increase EHR burden, such as when policy changes require thousands of individual templates be updated simultaneously. Fragmentation may also make it easier for clinicians to continue using templates with outdated clinical guidance.”

Rule & Hribar (2022), Journal of the American Medical Informatics Association

This uncoordinated duplication creates valid challenges and wastes everyone’s time. For example, researchers found that providers had created 103 different templates documenting responses to the same set of contraindication questions for a flu vaccine.

EHR note templates today are fragmented: providers create templates that align well with their documentation workflow but don’t share them. As a result, many templates accomplish the same thing, but there’s no communication or standardization between users.

EHR note personalization vs. standardization

Providers like EHR templates, and it’s logical to personalize them. But a lack of standardization creates extra work and poses quality challenges. So what’s the solution? 

Researchers say EHR designers should consider how health systems might use templates more like an application programming interface (API). This connection seems natural, given that modern note templates are similar to APIs: custom functions that interpolate text and data, are invoked by typing, and can modify the user interface (e.g., render a dropdown list).

Treating template development like APIs would mean developing standards for naming, documentation, and scope of use. Individual developers and clinicians could then tailor default templates to their unique workflows while preserving a link to the original version to propagate changes without overwriting their edits.

But what can individual physicians do while they wait for health systems and software vendors to change EHR templates?

Start by sharing your carefully-optimized templates with colleagues and residents. And consider working with your office or colleagues to standardize the note templates you use for similar visit types.
There’s evidence that implementing standard note templates can increase note quality and reduce documentation time. Sharing can quickly address many of note templates’ challenges, ensuring that your EHR documentation is accurate and efficient.

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