Optimizing Office EHRs Principle 7: Reduce Cognitive Load

Principle 7 of a 12-part series on Optimizing Office EHRs

"Saved Time" will Keep Us Together

Learn to Reduce Cognitive Load

You may initially not understand "reduce cognitive load." Cognitive load refers to the mental efforts we place on our working memory (what I like to call "human RAM). After all, cognition, or thinking, is what the physician does best.  We think through patients' signs and symptoms to determine differential diagnoses.  We create treatment plans, perform procedures and/or manage disease states.  Any unnecessary steps in that process become detrimental to our efforts to deliver safe and effective care. It becomes important to eliminate non-critical mental processes in order to reduce cognitive load for the physician.  This saves time and pays huge dividends.

Many elements contribute to "unnecessary" cognitive load:

  • Interruptions throughout the day due to internal and external information requests.
  • Excessive "false" alerts within the EHR.
    Silhouette of a man's head showing data loading into the brain. A problem to solve if we want to reduce cognitive load.
    With the mental demands of patient care, we should welcome ways to reduce cognitive load.
  • The physician's effort to recall specific details of a patient visit in the context of 20 or more patients.
  • Viewing fragmented data about the patient, and assimilating it into congruent information for decision-making.
  • Working excessive hours, such as completing administrative and documentation tasks outside of office, especially on evenings and weekends.

Principle 7 addresses the ways to reduce the cognitive load through the use of your office EHR. Many physicians make office documentation too hard. I know I did.

"Business as Usual", didn't seem right when I went to an EMR

Prior to my EMR, I dictated my office notes. I typically did them after-hours, when I was already tired.  Since I saw 25-35 patients a day, it was sometimes difficult to keep all the details straight, even though I jotted-down notes during the visit. And then I had to review/approve the transcribed notes a couple of days later.  Thus, I was spending much more time per chart than I desired. In addition, I incurred transcription costs.

So when I implemented the EMR in 1993, I wanted to save time. I wanted to redesign office processes around having notes completed immediately. I didn't understand the benefits at the time. Surprisingly, within a month, I had cut my daily work by 2-3 hours.  I saw that this was mainly due to real time documentation. That amounted to about 50 hours each month. That is a huge amount of time savings over a year.

For many, it is hard to believe...

It seems impossible at first. Yet, looking at the big picture, it becomes apparent why it works. So I am asking you to suspend your disbelief for 10-15 minutes and consider the end-game.  Stop taking work home.  Stop being burned-out every weekend. Discover more family time.

The excess cognitive load of delayed documentation

To better understand the impact and opportunity, let's review the workflow of delayed office notes and not using the EHR as a real-time tool. I have seen some common scenarios around non-optimal EHR use:

First, someone has probably printed part of the chart for reference (creating waste in both the printing and the later secure disposal/shredding). Then the physician is jotting down notes. Typically, if prescriptions are needed, those may be e-prescribed or printed.  The physician misses the opportunity to review/update longitudinal elements of the EHR (such as Problem list and meds).  Yes, you can review on paper, but not immediately update. If the physician does not complete the note while the patient is in the office, the staff cannot provide a complete "clinical summary" of the visit or a note if sent for a consult or referral.

When the physician later completes the note, he/she typically re-accesses the chart (waste). The physician either completes the note using EMR tools, front-end voice recognition or back-end dictation/transcription.  In the latter case, the physician goes back to "authenticate" the transcribed report 2-3 days later.  Because the note is done outside of the exam room, the physician spends considerable cognitive load in recreating the mental story of the visit.  This creates more documentation "errors of omissions" (leaving out key details) and commission (confusing the details of one patient with another.).  Based on my experience with offices doing both immediate and delayed documentation, the latter usually creates a 50-100%+ increase in effort and time  due to the difficulties of recall.

During this completion gap, the staff and physician do not have the information of the visit readily available if a pharmacy or the patient calls for clarity (more waste).  So the staff has to interrupt the physician, in order to address the caller. Thus more waste and more cognitive load.  This is a non-productive cycle that you can break.

Other ways to reduce cognitive load:

Two other opportunities include working with your "EHR fixer" to

  • Refine your clinical decision support (CDS) rules to minimize false positives.
  • Create or  teach you where to find summary views within your EHR to pull together the data and information available for decision-making.

In summary, redesigning your documentation process and working with your "EHR fixer" will reduce cognitive load and save time. It will also eliminate waste (Principle #6), help you better use your EMR as an EHR (Principle #4) and set you up for Principle #8 (being patient-focused - coming next week). The following tips will help you be successful.

Principle #7: Reduce Cognitive Load

Three factors will help you reduce cognitive load in your day:

  1. Complete office documentation as you go.
  2. Think information push, not data pull.
  3. Be patient-focused

The tips for real-time documentation:

  1. Do not print prior notes that are already in the EHR.
  2. Have a device to view the EHR in each exam room. This can be a fixed desktop or a mobile/tablet device.
  3. Practice good cybersecurity hygiene.  Do not leave unattended devices logged in.  Single-sign-on strategies help here.  However, lacking that, at least lock your screen when you walk away form a device.
  4. Make sure your medical assistant has documented a good chief complaint and history in the EHR, along with reviewing and updating current meds, problems, new complaints, social/family history, etc., and recorded vital signs. Also he/she should note any potential refills requests.
    • Make sure that information automatically pre-populates your physician documentation. You should be able to edit that documentation.
    • If your EHR accepts patient-reported information such as review of system or assessments, make sure you are leveraging that capability.
  5. Ensure that your EMR provides a good summary screen that makes it easy to view your last note and critical information about the patient.
  6. Be prepared to walk in the room and focus first on the patient.  We all know that touch (such as a handshake) and acknowledgement of the patient's name is important to the therapeutic relationship.
    • Then confirm your assistant's documentation in the EHR, rather than ask the same questions.  Patients hate being asked three times "Do you have any allergies?" Instead, state with confidence, "I remember that you are allergic to penicillin."
    • They will be more open when you ask, "How often do you think you miss a dose of your blood pressure medicine, lisinopril?"
    • Avoid any negative statements/complaints about your EHR in front of the patient.  Instead use the EHR to show the patient an image or a clinical trend such as a lab or BP.
  7. Perform your history, exam, and then say to the patient, "Let me make a few notes, now. I may have some more questions.  Please interrupt me if you have any questions."  Document your note. Capture something important to the patient in your note for the follow up visit (This will be discussed more under Principle 8).
  8. Make sure at some point you discuss the treatment plan and ensure patient comprehension.
    • If you use front-end speech recognition software, dictate in the presence of the patient.  If you get any details wrong or the patient doesn't understand, the patient may let you know. It is better to have the patient leave with clarity rather than calling back later.
  9. Transmit any new prescriptions so that they will be included in your documentation along with your follow-up plan.  Quickly review and authenticate the note.
  10. If there is any pending decision-making, consider doing an addendum later, rather than delaying your note at the time of the visit.

You will obviously need to adapt this workflow to your specialty and situation.  However, the goal is to have the note done before you leave the room. Therefore the EHR is always up to date.  And if the patient grabs your assistant with "one more question" before they leave, your staff will have the tools and information to address it.  Also, the patient can get a complete clinical summary before leaving.  You staff can also provide immediate office notes for any referrals or consultations.

If you have a referral practice, leverage your EMR tools to generate a cover letter for referring physicians as well as one for consultation.  These are great time savers if done well.

Think Push not Pull

I have seen additional waste when physicians must go to multiple locations in the EMR to see vital signs, labs, notes, problems, allergies, etc.  It is like going to a file cabinet and pulling multiple files to get the information necessary to direct the patient's care.  Instead, the EHR should be like the scoreboard at the sports arena.  All the critical decision-making data and information is pushed to one screen so that you don't have to temporarily store multiple data points in your memory.  Instead, the associations "pop" before you.  This is an important aspect of how your EHR can save you time and reduce cognitive load.

I frequently find physicians who either have summary screens that they never use, or the summary screens are not pertinent to their needs.  This is where you can contact your "EHR fixers" locally and have them assist you.

In Principle 8, I will expand on these time savers under the principle of patient-focused care.  I hope you take advantage of these techniques to save you time and reduce cognitive load.  You will feel less like an EHR victim if you are able to accomplish your office work in less time and with less effort.  But it will take commitment and practice.  Most can get to real-time documentation within 30 days with dedicated effort.

Action Plan for Principle #7: Reduce Cognitive Load

Reduce Cognitive Load in your practice:

  • Finish each EHR note before moving on to the next patient.  It will be difficult at first.
    • Always start your focus with your patient through the history and exam.
    • Document with the patient in the room.
    • Confirm at least one key element of the visit with the patient. Look at the patient when doing this.
    • Encourage the patient to ask questions.
  • Find places in your EMR to view optimal summaries, rather than hunt and peck through the EHR.
  • Make sure your clinical assistant is working to the top of his/her license.
  • Reduce unnecessary alerts (a later topic).

Your goal is to get to full volume within two weeks, and rarely ever document outside of office hours.


Catch the Introduction for this series:


More on the 12 Principles for Optimizing the Office EHR (Published weekly):

  1. Know what you want. See First, do no (EHR) harm
  2. Commit to moving forward. See Don’t look back
  3. See your EHR as a practice improvement activity.  See Where do we begin? 
  4. Use Your EMR as an EHR. See "Is Your EMR as an EHR? "
  5. Eliminate Waste.  See "A penny saved, is better than a poke in the eye"
  6. Make the EHR Work for You. See "Know thyself".
  7. Reduce Cognitive Load.  See “Saved time will keep us together" on this page.
  8. Whenever I call you “friend”
  9. Read between the lines
  10. First measure the cost
  11. Eating the elephant one bite at a time
  12. Nothing’s “gonna” stop us now.

The 10 Myths of Office EHR

Myth #1:  I don't own my EHR, so I cannot fix it.

Myth #2: We have the wrong EHR for my practice.

Myth #3:  There is no way the EHR can save me time.

Myth #4:  I just need to go back to paper charts.

Myth #5:  EHR office notes are never going to be usable.

Myth #6:  The EHR cannot make my patients safer.

Myth #7: I don't have the time to fix my EHR.

Myth #8:  It's not up to me to fix my EHR.

Myth #9:  To use my EHR, I have to see less patients.

Myth #10: You don't understand, my practice is different.

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