The Challenges of Information Review in Primary Care

“While AI tools like just-in-time summaries or conversational agents that access patient data can certainly help streamline the review process, they’re not a comprehensive solution. Ideally, clinicians shouldn’t need to search for or surface information at all—because the information should never be lost to begin with.”

As primary care physicians, our chart review workflows vary depending on the scenario. Whether reviewing a new patient, managing an urgent care visit, or doing a deep dive into a chronic issue, each situation demands a unique approach. However, many electronic health records (EHRs) offer only basic search and filter tools, which fail to meet the real needs of clinicians.

In primary care, these varied workflows play out daily:

1. New Patient Review: Thoroughly going through medications, allergies, family and social history, surgical and medical history, recent labs, imaging, and specialist consultations.

2. Urgent Care Visits: A brief review of medications and allergies, with a focus on relevant past consultations or your own last note.

3. Follow-Up on Recent Changes: We conduct a comprehensive review of our own notes, labs, images, and consultations to make sure the recent changes in symptoms, diagnoses, or treatments are progressing as expected.

4. Deep Dive into a Specific Problem: For complex, long-standing conditions like hypertension, we need to trace which medications have been tried, what’s failed, and how lab trends have evolved over time.

5. “Buried Treasure” Hunting: Sometimes, we need to find crucial pieces of data—like a pathology report or a specialist letter—that are hidden deep in the patient’s record, which can make the search feel like looking for a needle in a haystack.

Despite this clear variety, many EHRs aren’t designed to support these distinct workflows. The pain points are familiar to every clinician:

• Lost time spent scrolling through irrelevant notes or searching for key data.

• Cognitive overload caused by the excess of unorganized or outdated information.

• Increased risk of errors, such as overlooking a critical lab result or treatment detail, buried in the mass of unfiltered data.

Why Better Organization is Key

While AI tools like just-in-time summaries or conversational agents that access patient data can certainly help streamline the review process, they’re not a comprehensive solution. Ideally, clinicians shouldn’t need to search for or surface information at all—because the information should never be lost to begin with.

A better, more sustainable solution lies in properly organizing the chart. By ensuring that patient information is stored in a clean, intuitive, and problem-focused manner, we can prevent the chart from becoming a chaotic, overwhelming ocean of data. Even with a wealth of information, an organized chart makes it easy to quickly access relevant details without relying solely on AI tools to locate buried information.

Facilitating Collaboration Across Teams

In addition to supporting individual workflows, problem-oriented documentation facilitates team collaboration, which is crucial in modern care settings. Whether it’s between specialists and primary care physicians, or across different departments in a hospital, organized, problem-based records ensure that everyone involved in the patient’s care has access to clear, up-to-date information. This streamlines communication and reduces the risk of miscommunication or conflicting treatment plans, improving patient outcomes.

Moving Towards a Solution

At River Records, we’re focused on building tools that tackle this very problem. Our approach centers around problem-based organization that mirrors how clinicians naturally think and work. By aligning our systems with how medical chart review is actually done, we ensure that critical information is always accessible when needed—without needing to hunt through endless notes or rely solely on AI-generated summaries.

In an upcoming post, we’ll dive into the documentation generation process, exploring how clinicians can more effectively capture data. But for now, know that we’re working to develop solutions that improve chart review by making it less time-consuming and more aligned with how clinicians actually work.

Stay tuned as we continue to explore how these tools can support the full spectrum of clinical workflows!