Department NLM Postdoc and Faculty Publish Ten-Year Study of Note Bloat

A postdoc and several faculty from the Department of Medical Informatics & Clinical Epidemiology (DMICE) at Oregon Health & Science University (OHSU) recently confirmed what many clinicians have long suspected: clinical notes are getting longer. In a study of nearly 3 million notes written across a decade, the team found outpatient progress notes written at OHSU grew 60% longer between 2009 and 2018, reaching an average length of 650 words by 2018.

After nearly every outpatient encounter, clinicians write a progress note describing the visit. The primary purpose of these notes is to tell clinicians taking care of the same patient in the future what happened during the visit, though such notes are now used for a variety of other purposes such as to justify billing or provide data for quality improvement.

Many clinicians have observed that clinical notes seem to be getting longer over time, a phenomena widely referred to as “note bloat”. Some have suggested that note bloat may be the result of overly prescriptive documentation requirements or the widespread use of tools such as copy-paste to write notes in electronic health records. Yet, according to the team’s paper, the reasons for note bloat may be more complex.

Looking at notes written in 2018, the team found only 30% of text in the typical note had been manually written, with 56% coming from note templates and just 14% from copy-paste. While notes that had more of their text come from templates and copy-pasting tended to be longer, medical trainees (i.e., residents and fellows) and more recent hires also wrote longer notes. For example, after controlling for other factors, clinicians hired in 2018 were found to write notes that were 26% longer than those written by clinicians hired in 2005.

These findings provide quantitative evidence for the widely observed but poorly measured phenomena of note bloat. While longer notes may provide useful information about a patient’s care, there is concern that many notes may be full of unnecessary text included primarily to meet billing or regulatory requirements. Some notes may now be too long for providers to meaningfully review during already packed clinic days. However, recent changes to regulation—such as the Center for Medicare and Medicaid Services reducing their documentation requirements for outpatient visits—may be providing clinicians with an opportunity to rethink what they include in their notes.

See the team’s paper in JAMA Network Open for full details.

We are also pleased to report that the lead author of the paper, Adam Rule, PhD, recently finished his two-year postdoctoral fellowship with DMICE, funded by our National Library of Medicine T15 training grant. Dr. Rule will be joining the Information School at the University of Wisconsin-Madison as an assistant professor this fall.

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