ArticleJournal of the American Medical Informatics Association : JAMIA2015
Electronic health records improve clinical note quality.
Article in Journal of the American Medical Informatics Association : JAMIA, 2015. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 33 papers, 2 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
33 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Strategies for improving physician documentation in the emergency department: a systematic review.BMC emergency medicine · 2018Pooled it
- The use of Electronic Health Records to Support Population Health: A Systematic Review of the Literature.Journal of medical systems · 2018Pooled it
- Delivering person-centered care with an electronic health record.BMC medical informatics and decision making · 2019Trial
- An electronic documentation system improves the quality of admission notes: a randomized trial.Journal of the American Medical Informatics Association : JAMIA · 2017Trial
- Application of digital simulations for clinical assessment and documentation of temporomandibular disorders: a retrospective study.Oral surgery, oral medicine, oral pathology and oral radiology · 2026Article
- Clinicians' rationale for editing ambient AI-drafted clinical notes: persistent challenges and implications for improvement.Journal of the American Medical Informatics Association : JAMIA · 2026Article
- Comparing audiovisual visit and in-person visit note quality.JAMIA open · 2026Article
- Accuracy of large language model transcription of simulated physician-patient verbal interactions.BMC medical informatics and decision making · 2026Article
- Large language model evaluation and feedback of transcribed simulated physician-patient verbal interactions.Frontiers in artificial intelligence · 2026Article
- Improving completion of the red reflex examination at neonatal intensive care unit discharge: a practice improvement initiative and multisite planned experiment.BMJ open quality · 2025Article
- The health data utility and the resurgence of health information exchanges as a national resource.Journal of the American Medical Informatics Association : JAMIA · 2025Article
- Assessing Physician and Patient Agreement on Whether Patient Outcomes Captured in Clinical Progress Notes Reflect Treatment Success: Cross-Sectional Study.Journal of participatory medicine · 2025Article
- Assessing the Ability of a Large Language Model to Score Free-Text Medical Student Clinical Notes: Quantitative Study.JMIR medical education · 2024Article
- A Multiyear Survey Evaluating Clinician Electronic Health Record Satisfaction.Applied clinical informatics · 2023Article
- Evaluating the Impact on Clinical Task Efficiency of a Natural Language Processing Algorithm for Searching Medical Documents: Prospective Crossover Study.JMIR medical informatics · 2022Article
- The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.Journal of medical systems · 2022Article
- Monitoring of Adverse Drug Reaction-Related Parameters in Children, Youth, and Young Adults Prescribed Antipsychotic Drugs by General Practitioners.Journal of child and adolescent psychopharmacology · 2022Article
- Improving clinical documentation: introduction of electronic health records in paediatrics.BMJ open quality · 2021Article
- Clinical Note Section Detection Using a Hidden Markov Model of Unified Medical Language System Semantic Types.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2021Article
- Monitoring of Adverse Drug Reaction-Related Parameters in Children and Adolescents Treated With Antipsychotic Drugs in Psychiatric Outpatient Clinics.Frontiers in psychiatry · 2021Article
Corrections and comments
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Authors and funding
24 authors.
Funding
Abstract
BACKGROUND AND
objectiveThe 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. MATERIALS AND
methodsA 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.
resultsThe 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.
conclusionsThe 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.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.