J Am Med Inform Assoc 19:1019-1024 doi:10.1136/amiajnl-2011-000788
  • Research and applications

Method of electronic health record documentation and quality of primary care

  1. Blackford Middleton1,3
  1. 1Division of General Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
  2. 2BWH Hospitalist Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Clinical Informatics Research and Development, Partners HealthCare System, Boston, Massachusetts, USA
  1. Correspondence to Dr Jeffrey A Linder, Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, BC-3-2X, Boston, MA 02120, USA; jlinder{at}
  • Received 20 December 2011
  • Accepted 25 April 2012
  • Published Online First 19 May 2012


Objective Physicians who more intensively interact with electronic health records (EHRs) through their documentation style may pay greater attention to coded fields and clinical decision support and thus may deliver higher quality care. We measured the quality of care of physicians who used three predominating EHR documentation styles: dictation, structured documentation, and free text.

Methods We conducted a retrospective analysis of visits by patients with coronary artery disease and diabetes to the Partners Primary Care Practice Based Research Network. The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after primary care visits.

Results During the 9-month study period, 7000 coronary artery disease and diabetes patients made 18 569 visits to 234 primary care physicians of whom 20 (9%) predominantly dictated their notes, 68 (29%) predominantly used structured documentation, and 146 (62%) predominantly typed free text notes. In multivariable modeling adjusted for clustering by patient and physician, quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam); better for structured documenters for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam); and better for free text documenters on one measure (influenza vaccination). There was no measure for which dictators had higher quality of care than physicians using the other two documentation styles.

Conclusions EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.

Clinical trial registration number Identifier: NCT00235040.


  • Funding This study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS015169). Dr Linder was supported by a career development award (K08 HS014563) from the Agency for Healthcare Research and Quality. Dr Schnipper was supported by a mentored career development award from the National Heart, Lung, and Blood Institute (K08 HL072806). The sponsors had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. The authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by Partners HealthCare Human Research Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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