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Hwang TS, Thomas M, Hribar M, Chen A, White E. The Impact of Documentation Workflow on the Accuracy of the Coded Diagnoses in the Electronic Health Record. OPHTHALMOLOGY SCIENCE 2024; 4:100409. [PMID: 38054107 PMCID: PMC10694743 DOI: 10.1016/j.xops.2023.100409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 12/07/2023]
Abstract
Objective To determine the impact of documentation workflow on the accuracy of coded diagnoses in electronic health records (EHRs). Design Cross-sectional study. Participants All patients who completed visits at the Casey Eye Institute Retina Division faculty clinic between April 7, 2022 and April 13, 2022. Main Outcome Measures Agreement between coded diagnoses and clinical notes. Methods We assessed the rate of agreement between the diagnoses in the clinical notes and the coded diagnosis in the EHR using manual review and examined the impact of the documentation workflow on the rate of agreement in an academic retina practice. Results In 202 visits by 8 physicians, 78% (range, 22%-100%) had an agreement between the coded diagnoses and the clinical notes. When physicians integrated the diagnosis code entry and note composition, the rate of agreement was 87.9% (range, 62%-100%). For those who entered the diagnosis codes separately from writing notes, the agreement was 44.4% (22%-50%, P < 0.0001). Conclusion The visit-specific agreement between the coded diagnosis and the progress note can vary widely by workflow. The workflow and EHR design may be an important part of understanding and improving the quality of EHR data. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Thomas S. Hwang
- Casey Eye Institute, Oregon Health and Science University, Portland, OR
| | - Merina Thomas
- Casey Eye Institute, Oregon Health and Science University, Portland, OR
| | - Michelle Hribar
- Casey Eye Institute, Oregon Health and Science University, Portland, OR
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR
| | - Aiyin Chen
- Casey Eye Institute, Oregon Health and Science University, Portland, OR
| | - Elizabeth White
- Casey Eye Institute, Oregon Health and Science University, Portland, OR
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Guo AH, Diaz-Caturan MV, Reis C, Carritte D, Smith BMT, Wester YO, Hall SL. Practical Strategies and Tools for Use by Occupational and Environmental Medicine Departments During COVID-19 Pandemic Surges. J Occup Environ Med 2022; 64:10-18. [PMID: 34538840 PMCID: PMC8715935 DOI: 10.1097/jom.0000000000002390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Occupational and environmental medicine (OEM) departments in healthcare institutions can be quickly overwhelmed when COVID-19 infection rates rapidly and simultaneously increase in the workforce and the patients served. Our goal is to present a detailed toolkit of practical approaches for use by front-line OEM specialists to address workforce management tasks during pandemic surges. METHODS Specific focus is on tasks related to employee symptom triage, exposure risk assessment, workplace contact tracing, and work restrictions. RESULTS Tools include strategies used by customer call centers, two decision support algorithms (exposure due to cohabitation or non-cohabitation), a color-coded employee case tracking tool, a contact tracing protocol, and documentation templates that serve as memory aids for encounters. CONCLUSIONS These tools are created with commonly used software. Implementation is feasible in most front-line OEM settings, including those with limited resources.
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Affiliation(s)
- Andrew H Guo
- Veterans Affairs Loma Linda Healthcare System, Loma Linda, California (Dr Guo, Diaz-Caturan, Dr Reis, Dr Carritte, Dr Smith, Dr Wester, Dr Hall), Loma Linda University, School of Medicine, Loma Linda, California (Dr Guo, Dr Reis, Dr Carritte, Dr Hall), Linda University, School of Public Health Loma Linda, California (Dr Reis, Dr Hall), Southern California University of Health Sciences (Dr Smith), Loma Linda University Health (Dr Wester)
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3
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Weir CR, Taber P, Taft T, Reese TJ, Jones B, Del Fiol G. Feeling and thinking: can theories of human motivation explain how EHR design impacts clinician burnout? J Am Med Inform Assoc 2021; 28:1042-1046. [PMID: 33179026 DOI: 10.1093/jamia/ocaa270] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/28/2020] [Indexed: 01/09/2023] Open
Abstract
The psychology of motivation can help us understand the impact of electronic health records (EHRs) on clinician burnout both directly and indirectly. Informatics approaches to EHR usability tend to focus on the extrinsic motivation associated with successful completion of clearly defined tasks in clinical workflows. Intrinsic motivation, which includes the need for autonomy, sense-making, creativity, connectedness, and mastery is not well supported by current designs and workflows. This piece examines existing research on the importance of 3 psychological drives in relation to healthcare technology: goal-based decision-making, sense-making, and agency/autonomy. Because these motives are ubiquitous, foundational to human functioning, automatic, and unconscious, they may be overlooked in technological interventions. The results are increased cognitive load, emotional distress, and unfulfilling workplace environments. Ultimately, we hope to stimulate new research on EHR design focused on expanding functionality to support intrinsic motivation, which, in turn, would decrease burnout and improve care.
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Affiliation(s)
- Charlene R Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Peter Taber
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Teresa Taft
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Thomas J Reese
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Barbara Jones
- Department of Veteran's Affairs IDEAS Center, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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Rundo L, Pirrone R, Vitabile S, Sala E, Gambino O. Recent advances of HCI in decision-making tasks for optimized clinical workflows and precision medicine. J Biomed Inform 2020; 108:103479. [DOI: 10.1016/j.jbi.2020.103479] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/27/2020] [Accepted: 06/06/2020] [Indexed: 12/28/2022]
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Overhage JM, McCallie D. Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study. Ann Intern Med 2020; 172:169-174. [PMID: 31931523 DOI: 10.7326/m18-3684] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The amount of time that providers spend using electronic health records (EHRs) to support the care delivery process is a concern for the U.S. health care system. Given the potential effect on patient care and the high costs related to this time, particularly for medical specialists whose work is largely cognitive, these findings warrant more precise documentation of the time physicians invest in these clinically focused EHR functions. OBJECTIVE To describe how much time ambulatory medical subspecialists and primary care physicians across several U.S. care delivery systems spend on various EHR functions. DESIGN Descriptive study. SETTING U.S.-based, adult, nonsurgical, ambulatory practices using the Cerner Millennium EHR. PARTICIPANTS 155 000 U.S. physicians. MEASUREMENTS Data were extracted from software log files in the Lights On Network (Cerner) during 2018 that totaled the time spent on each of the 13 clinically focused EHR functions. Averages per encounter by specialty were computed. RESULTS This study included data from approximately 100 million patient encounters with about 155 000 physicians from 417 health systems. Physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. The distribution of time spent by providers using EHRs varies greatly within specialty. The proportion of time spent on various clinically focused functions was similar across specialties. LIMITATION Variation by health system could not be examined, and all providers used the same software. CONCLUSION The time spent using EHRs to support care delivery constitutes a large portion of the physicians' day, and wide variation suggests opportunities to optimize systems and processes. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
| | - David McCallie
- Cerner Corporation, Kansas City, Missouri (J.M.O., D.M.)
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Cheng DR, Katz ML, South M. Integrated Electronic Discharge Summaries-Experience of a Tertiary Pediatric Institution. Appl Clin Inform 2018; 9:734-742. [PMID: 30231259 DOI: 10.1055/s-0038-1669461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Succinct and timely discharge summaries (DSs) facilitate ongoing care for patients discharged from acute care settings. Many institutions have introduced electronic DS (eDS) templates to improve quality and timeliness of clinical correspondence. However, significant intrahospital and intraunit variability and application exists. A review of the literature and guidelines revealed 13 key elements that should be included in a best practice DS. This was compared against our pediatric institution's eDS template-housed within an integrated electronic medical record (EMR) and used across most inpatient hospital units. METHODS Uptake and adherence to the suggested key elements was measured by comparing all DSs for long stay inpatients (> 21-day admission) during the first year of the EMR eDS template's usage (May 2016-April 2017). RESULTS A total of 472 DSs were evaluated. Six of 13 key elements were completed in > 98.0% of DSs. Conversely, only < 5.0% included allergies or adverse reaction data, and < 11.0% included ceased medications or pending laboratory results. Inclusion of procedure information and pending laboratory results significantly improved with time (p = 0.05 and p < 0.04, respectively), likely as doctors became more familiar with EMR and autopopulation functions. Inclusion of "discharge diagnosis" differed significantly between medical (n = 406/472; 99.0%) and surgical (n = 32/472; 51.6%) DSs. CONCLUSION Uptake and adherence to an EMR eDS template designed to meet best practice guidelines in a pediatric institution was strong, although significant improvements in specific data elements are needed. Strategies can include a modification of existing eDS templates and junior medical staff education around best practice.
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Affiliation(s)
- Daryl R Cheng
- EMR Project Team, The Royal Children's Hospital Melbourne, Parkville, Australia.,Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Merav L Katz
- EMR Project Team, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Mike South
- EMR Project Team, The Royal Children's Hospital Melbourne, Parkville, Australia.,Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Australia
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Rosenbloom ST, Stead WW, Denny JC, Giuse D, Lorenzi NM, Brown SH, Johnson KB. Generating Clinical Notes for Electronic Health Record Systems. Appl Clin Inform 2017; 1:232-243. [PMID: 21031148 DOI: 10.4338/aci-2010-03-ra-0019] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system. Based on their experience rolling out an EHR system that supports multiple methods for clinical documentation, the authors recommend that documentation method selection be made on the basis of clinical workflow, note content standards and usability considerations, rather than on a theoretical need for structured data.
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Affiliation(s)
- S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
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8
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Calvitti A, Hochheiser H, Ashfaq S, Bell K, Chen Y, El Kareh R, Gabuzda MT, Liu L, Mortensen S, Pandey B, Rick S, Street RL, Weibel N, Weir C, Agha Z. Physician activity during outpatient visits and subjective workload. J Biomed Inform 2017; 69:135-149. [PMID: 28323114 DOI: 10.1016/j.jbi.2017.03.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 03/14/2017] [Accepted: 03/16/2017] [Indexed: 12/25/2022]
Abstract
We describe methods for capturing and analyzing EHR use and clinical workflow of physicians during outpatient encounters and relating activity to physicians' self-reported workload. We collected temporally-resolved activity data including audio, video, EHR activity, and eye-gaze along with post-visit assessments of workload. These data are then analyzed through a combination of manual content analysis and computational techniques to temporally align streams, providing a range of process measures of EHR usage, clinical workflow, and physician-patient communication. Data was collected from primary care and specialty clinics at the Veterans Administration San Diego Healthcare System and UCSD Health, who use Electronic Health Record (EHR) platforms, CPRS and Epic, respectively. Grouping visit activity by physician, site, specialty, and patient status enables rank-ordering activity factors by their correlation to physicians' subjective work-load as captured by NASA Task Load Index survey. We developed a coding scheme that enabled us to compare timing studies between CPRS and Epic and extract patient and visit complexity profiles. We identified similar patterns of EHR use and navigation at the 2 sites despite differences in functions, user interfaces and consequent coded representations. Both sites displayed similar proportions of EHR function use and navigation, and distribution of visit length, proportion of time physicians attended to EHRs (gaze), and subjective work-load as measured by the task load survey. We found that visit activity was highly variable across individual physicians, and the observed activity metrics ranged widely as correlates to subjective workload. We discuss implications of our study for methodology, clinical workflow and EHR redesign.
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Affiliation(s)
- Alan Calvitti
- Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States.
| | - Harry Hochheiser
- Department of Biomedical Informatics and Intelligent Systems Program, University of Pittsburgh, 5607 Baum Blvd, Pittsburgh, PA 15206, United States
| | - Shazia Ashfaq
- Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States
| | - Kristin Bell
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, United States
| | - Yunan Chen
- Department of Medical Informatics UC Irvine, Irvine, CA 92697, United States
| | - Robert El Kareh
- Department of Hospital Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States
| | - Mark T Gabuzda
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, United States
| | - Lin Liu
- Department of Family Medicine and Public Health, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States
| | - Sara Mortensen
- Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States
| | - Braj Pandey
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, United States
| | - Steven Rick
- Department of Computer Science and Engineering, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States
| | - Richard L Street
- Department of Communication, Texas A&M University, 400 Bizzell St, College Station, TX 77840, United States
| | - Nadir Weibel
- Department of Computer Science and Engineering, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, SLC, VA, Salt Lake City, UT, United States
| | - Zia Agha
- Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States; Department of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States; West Health Institute, 10350 N. Torrey Pines Road, La Jolla, CA 92037, United States
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9
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Abstract
Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre- and 610 notes post-template introduction were identified. Note length was 263 characters shorter ( P = .004) and mean end time was 73 minutes later ( P < .0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template ( P < .01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR's contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.
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Affiliation(s)
- Megan Aylor
- 1 Oregon Health & Science University, Portland, OR, USA
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10
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Quality Documentation in the Electronic Medical Record: Ensuring Safe Practice of Copy and Paste. CLIN NURSE SPEC 2016; 30:190-3. [PMID: 27309780 DOI: 10.1097/nur.0000000000000214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Cognitive informatics methods for interactive clinical systems. J Biomed Inform 2016. [DOI: 10.1016/j.jbi.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Rizvi RF, Harder KA, Hultman GM, Adam TJ, Kim M, Pakhomov SVS, Melton GB. A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians. Int J Med Inform 2016; 90:1-11. [PMID: 27103191 DOI: 10.1016/j.ijmedinf.2016.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 02/25/2016] [Accepted: 02/27/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective of this study is to understand physicians' usage of inpatient notes by (i) ascertaining different clinical note-entry and reading/retrieval styles in two different and widely used Electronic Health Record (EHR) systems, (ii) extrapolating potential factors leading to adoption of various note-entry and reading/retrieval styles and (iii) determining the amount of time to task associated with documenting different types of clinical notes. METHODS In order to answer "what" and "why" questions on physicians' adoption of certain-note-entry and reading/retrieval styles, an ethnographic study entailing Internal Medicine residents, with a mixed data analysis approach was performed. Participants were observed interacting with two different EHR systems in inpatient settings. Data was collected around the use and creation of History and Physical (H&P) notes, progress notes and discharge summaries. RESULTS The highest variability in template styles was observed with progress notes and the least variability was within discharge summaries, while note-writing styles were most consistent for H&P notes. The first sections to be read in a H&P and progress note were the Chief Complaint and Assessment & Plan sections, respectively. The greatest note retrieval variability, with respect to the order of how note sections were reviewed, was observed with H&P and progress notes. Physician preference for adopting a certain reading/retrieval order appeared to be a function of what best fits their workflow while fulfilling the stimulus demands. The time spent entering H&P, discharge summaries and progress notes were similar in both EHRs. CONCLUSION This research study unveils existing variability in clinical documentation processes and provides us with important information that could help in designing a next generation EHR Graphical User Interface (GUI) that is more congruent with physicians' mental models, task performance needs, and workflow requirements.
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Affiliation(s)
- Rubina F Rizvi
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| | - Kathleen A Harder
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; Center for Design in Health, College of Design, University of Minnesota, Minneapolis, MN, United States
| | - Gretchen M Hultman
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| | - Terrence J Adam
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Michael Kim
- Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Serguei V S Pakhomov
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Genevieve B Melton
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; Department of Surgery, University of Minnesota, Minneapolis, MN, United States.
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Patel VL, Kannampallil TG. Cognitive informatics in biomedicine and healthcare. J Biomed Inform 2014; 53:3-14. [PMID: 25541081 DOI: 10.1016/j.jbi.2014.12.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 12/12/2014] [Accepted: 12/14/2014] [Indexed: 12/21/2022]
Abstract
Cognitive Informatics (CI) is a burgeoning interdisciplinary domain comprising of the cognitive and information sciences that focuses on human information processing, mechanisms and processes within the context of computing and computer applications. Based on a review of articles published in the Journal of Biomedical Informatics (JBI) between January 2001 and March 2014, we identified 57 articles that focused on topics related to cognitive informatics. We found that while the acceptance of CI into the mainstream informatics research literature is relatively recent, its impact has been significant - from characterizing the limits of clinician problem-solving and reasoning behavior, to describing coordination and communication patterns of distributed clinical teams, to developing sustainable and cognitively-plausible interventions for supporting clinician activities. Additionally, we found that most research contributions fell under the topics of decision-making, usability and distributed team activities with a focus on studying behavioral and cognitive aspects of clinical personnel, as they performed their activities or interacted with health information systems. We summarize our findings within the context of the current areas of CI research, future research directions and current and future challenges for CI researchers.
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Affiliation(s)
- Vimla L Patel
- Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, 1216 5th Avenue, New York, NY 10029, United States.
| | - Thomas G Kannampallil
- Department of Family Medicine, College of Medicine, University of Illinois at Chicago, 1919 W Taylor St (M/C 663), Chicago, IL 60612, United States.
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Neri PM, Volk LA, Samaha S, Pollard SE, Williams DH, Fiskio JM, Burdick E, Edwards ST, Ramelson H, Schiff GD, Bates DW. Relationship between documentation method and quality of chronic disease visit notes. Appl Clin Inform 2014; 5:480-90. [PMID: 25024762 DOI: 10.4338/aci-2014-01-ra-0007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/15/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases. METHODS Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods. RESULTS A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001). DISCUSSION There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists. CONCLUSION As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.
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Affiliation(s)
- P M Neri
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - L A Volk
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - S Samaha
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - S E Pollard
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - D H Williams
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA
| | - J M Fiskio
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - E Burdick
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA
| | - S T Edwards
- Harvard Medical School , Boston, MA ; Massachusetts Veteran's Epidemiology Research and Information Center, Veteran's Affairs Boston Healthcare System , Boston, MA ; Section of General Internal Medicine, Veteran's Affairs Boston Healthcare System , Boston, MA
| | - H Ramelson
- Information Systems, Partners Healthcare System , Wellesley, MA ; Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
| | - G D Schiff
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
| | - D W Bates
- Information Systems, Partners Healthcare System , Wellesley, MA ; Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
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Ho YX, Gadd CS, Kohorst KL, Rosenbloom ST. A qualitative analysis evaluating the purposes and practices of clinical documentation. Appl Clin Inform 2014; 5:153-68. [PMID: 24734130 DOI: 10.4338/aci-2013-10-ra-0081] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/17/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES An important challenge for biomedical informatics researchers is determining the best approach for healthcare providers to use when generating clinical notes in settings where electronic health record (EHR) systems are used. The goal of this qualitative study was to explore healthcare providers' and administrators' perceptions about the purpose of clinical documentation and their own documentation practices. METHODS We conducted seven focus groups with a total of 46 subjects composed of healthcare providers and administrators to collect knowledge, perceptions and beliefs about documentation from those who generate and review notes, respectively. Data were analyzed using inductive analysis to probe and classify impressions collected from focus group subjects. RESULTS We observed that both healthcare providers and administrators believe that documentation serves five primary domains: clinical, administrative, legal, research, education. These purposes are tied closely to the nature of the clinical note as a document shared by multiple stakeholders, which can be a source of tension for all parties who must use the note. Most providers reported using a combination of methods to complete their notes in a timely fashion without compromising patient care. While all administrators reported relying on computer-based documentation tools to review notes, they expressed a desire for a more efficient method of extracting relevant data. CONCLUSIONS Although clinical documentation has utility, and is valued highly by its users, the development and successful adoption of a clinical documentation tool largely depends on its ability to be smoothly integrated into the provider's busy workflow, while allowing the provider to generate a note that communicates effectively and efficiently with multiple stakeholders.
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Affiliation(s)
- Y-X Ho
- Department of Biomedical Informatics, Vanderbilt University School of Medicine , Nashville, TN
| | - C S Gadd
- Department of Biomedical Informatics, Vanderbilt University School of Medicine , Nashville, TN
| | - K L Kohorst
- Department of Anesthesiology, Vanderbilt University Medical Center , Nashville, TN
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Warner JL, Anick P, Drews RE. Physician inter-annotator agreement in the Quality Oncology Practice Initiative manual abstraction task. J Oncol Pract 2014; 9:e96-102. [PMID: 23942509 DOI: 10.1200/jop.2013.000931] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Quality Oncology Practice Initiative (QOPI) relies on the accuracy of manual abstraction of clinical data from paper-based and electronic medical records (EMRs). Although there is no "gold standard" to measure manual abstraction accuracy, measurement of inter-annotator agreement (IAA) is a commonly agreed-on surrogate. We quantified the IAA of QOPI abstractions on a cohort of cancer patients treated at Beth Israel Deaconess Medical Center. METHODS The EMR charts of 49 patients (20 colorectal cancer; 18 breast cancer; 11 non-Hodgkin lymphoma) were abstracted by separate physician abstractors in the fall 2010 and fall 2011 QOPI abstraction rounds. Cohen's kappa (κ) was calculated for encoded data; raw levels of agreement and magnitude of discrepancies were calculated for numeric and dated data. RESULTS One hundred two data elements with 2,035 paired entries were analyzed. Overall IAA for the 1,496 coded entries was κ = 0.75; median IAA for n = 85 individual coded elements was κ = 0.84 (interquartile range, 0.30 to 1.00). Overall IAA for the 421 dated entries was 73%; median IAA for n = 17 individual dated elements was 67% (interquartile range, 61% to 86%). CONCLUSION This study establishes a baseline level of IAA for a complex medical abstraction task with clear relevance for the oncology community. Given that the observed κ is considered only fair IAA, and that the rate of date discrepancy is high, caution is necessary in interpreting the results of QOPI and other manual abstractions of clinical oncology data. The accuracy of automated data extraction efforts, possibly including a future evolution of QOPI, will also need to be carefully evaluated.
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Shoolin J, Ozeran L, Hamann C, Bria W. Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation. Appl Clin Inform 2013; 4:293-303. [PMID: 23874365 DOI: 10.4338/aci-2013-02-r-0012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 06/11/2013] [Indexed: 11/23/2022] Open
Abstract
In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of 'note bloat'. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display.
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Affiliation(s)
- J Shoolin
- Advocate Healthcare , Glencoe, Illinois, USA.
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Embi PJ, Weir C, Efthimiadis EN, Thielke SM, Hedeen AN, Hammond KW. Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators. J Am Med Inform Assoc 2013; 20:718-26. [PMID: 23355462 PMCID: PMC3721152 DOI: 10.1136/amiajnl-2012-000946] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Clinical documentation is central to the medical record and so to a range of healthcare and business processes. As electronic health record adoption expands, computerized provider documentation (CPD) is increasingly the primary means of capturing clinical documentation. Previous CPD studies have focused on particular stakeholder groups and sites, often limiting their scope and conclusions. To address this, we studied multiple stakeholder groups from multiple sites across the USA. Methods We conducted 14 focus groups at five Department of Veterans Affairs facilities with 129 participants (54 physicians or practitioners, 34 nurses, and 37 administrators). Investigators qualitatively analyzed resultant transcripts, developed categories linked to the data, and identified emergent themes. Results Five major themes related to CPD emerged: communication and coordination; control and limitations in expressivity; information availability and reasoning support; workflow alteration and disruption; and trust and confidence concerns. The results highlight that documentation intertwines tightly with clinical and administrative workflow. Perceptions differed between the three stakeholder groups but remained consistent within groups across facilities. Conclusions CPD has dramatically changed documentation processes, impacting clinical understanding, decision-making, and communication across multiple groups. The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows. Current CPD systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated ‘paper-chart’ paradigm. These findings should inform those implementing CPD systems now and future plans for more effective CPD systems.
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Affiliation(s)
- Peter J Embi
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio 43210, USA.
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Hanson JL, Stephens MB, Pangaro LN, Gimbel RW. Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research. BMC Health Serv Res 2012; 12:407. [PMID: 23164470 PMCID: PMC3529118 DOI: 10.1186/1472-6963-12-407] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 10/30/2012] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND There are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders. METHODS Using purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding. RESULTS The 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content. CONCLUSIONS Perspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.
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Affiliation(s)
- Janice L Hanson
- Departments of Medicine, Pediatrics & Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Ave., B-158, Aurora, Colorado, 80045, USA
| | - Mark B Stephens
- Department of Family Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland, 20814, USA
| | - Louis N Pangaro
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland, 20814, USA
| | - Ronald W Gimbel
- Department of Biomedical Informatics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland, 20814, USA
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Hahn JS, Bernstein JA, McKenzie RB, King BJ, Longhurst CA. Rapid implementation of inpatient electronic physician documentation at an academic hospital. Appl Clin Inform 2012; 3:175-85. [PMID: 23620718 DOI: 10.4338/aci-2012-02-cr-0003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 04/23/2012] [Indexed: 01/01/2023] Open
Abstract
Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children's Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.
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Stetson P, Bakken S, Wrenn J, Siegler E. Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9). Appl Clin Inform 2012; 3:164-174. [PMID: 22577483 PMCID: PMC3347480 DOI: 10.4338/aci-2011-11-ra-0070] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 03/29/2012] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE: To refine the Physician Documentation Quality Instrument (PDQI) and test the validity and reliability of the 9-item version (PDQI-9). METHODS: Three sets each of admission notes, progress notes and discharge summaries were evaluated by two groups of physicians using the PDQI-9 and an overall general assessment: one gold standard group consisting of program or assistant program directors (n=7), and the other of attending physicians or chief residents (n=24). The main measures were criterion-related validity (correlation coefficients between Total PDQI-9 scores and 1-item General Impression scores for each note), discriminant validity (comparison of PDQI-9 scores on notes rated as best and worst using 1-item General Impression score), internal consistency reliability (Cronbach's alpha), and inter-rater reliability (intraclass correlation coefficient (ICC)). RESULTS: The results were criterion-related validity (r = -.678 to .856), discriminant validity (best versus worst note, t = 9.3, p = .003), internal consistency reliability (Cronbach's alphas = .87-.94), and inter-rater reliability (ICC = .83, CI = .72-.91). CONCLUSION: The results support the criterion-related and discriminant validity, internal consistency reliability, and inter-rater reliability of the PDQI-9 for rating the quality of electronic physician notes. Tools for assessing note redundancy are required to complement use of PDQI-9. Trials of the PDQI-9 at other institutions, of different size, using different EHRs, and incorporating additional physician specialties and notes of other healthcare providers are needed to confirm its generalizability.
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Affiliation(s)
- P.D. Stetson
- Correspondence to: Peter D. Stetson, MD, MA, Columbia University Medical Center, 650 West 168th Street, BB2–239, New York, NY 10032, , Phone: 212.342.0029
| | | | - J.O. Wrenn
- Department of Medical Informatics, Vanderbilt University
| | - E.L. Siegler
- Division of Geriatrics and Gerontology, Weill Cornell Medical College
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Holden RJ. What stands in the way of technology-mediated patient safety improvements?: a study of facilitators and barriers to physicians' use of electronic health records. J Patient Saf 2011; 7:193-203. [PMID: 22064624 PMCID: PMC3220192 DOI: 10.1097/pts.0b013e3182388cfa] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES For electronic health record (EHR) systems to have a positive impact on patient safety, clinicians must be able to use these systems effectively after they are made available. This study's objective is to identify and describe facilitators and barriers to physicians' use of EHR systems. METHODS Twenty research interviews were conducted with attending physicians who were using EHR at 1 of 2 Midwest community hospitals and/or at their respective outpatient clinics. RESULTS Analyses yielded more than 200 perceived facilitators and barriers, comprising 19 distinct categories. Categories of facilitators/barriers related to user attribute included learning, typing proficiency, understanding the EHR system, motivation/initiative, and strategies/workarounds. Categories related to system attributes were supporting hardware/software and system speed, functionality, and usability. Categories related to support from others were formal technical support, formal training, and informal support from colleagues. Categories of organizational facilitators/barriers were time allowance and interinstitutional integration. Categories of environmental facilitators/barriers were physical space, electricity, wireless connectivity, and the social environment. CONCLUSIONS Together, the broad set of discovered facilitators and barriers confirms and expands prior research on the facilitators and barriers to health information technology use. The depth of reported information on each facilitator and barrier made possible by qualitative interview methods contributes to the theoretical understanding of facilitators and barriers to EHR use. Equally as important, this study provides an information base from which relevant policy and design interventions can be launched to improve the use of EHR systems and, thus, patient safety.
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Affiliation(s)
- Richard J Holden
- Departments of Medicine and Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA.
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Weir CR, Hammond KW, Embi PJ, Efthimiadis EN, Thielke SM, Hedeen AN. An exploration of the impact of computerized patient documentation on clinical collaboration. Int J Med Inform 2011; 80:e62-71. [PMID: 21300565 DOI: 10.1016/j.ijmedinf.2011.01.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 11/03/2010] [Accepted: 01/09/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to explore the experience of experienced users of computerized patient documentation for the purpose of collaboration and coordination. A secondary analysis of qualitative data using Clark's theoretical framework of communication was conducted with the goal of bringing research findings into design. METHODS Physicians, nurses and administrative staff volunteered to participate in focus groups at 4 VA sites. Each focus group lasted 1.5h and targeted experience and issues with using computerized documentation. All focus groups were audio-taped and transcribed and submitted to extensive qualitative analysis using ATLAS, iterative identification of concepts and categories. The communication category was targeted for secondary theoretical analysis in order to deepen understanding of the findings. Clark's theory of communication, joint action and common ground heuristics was used to analyze concepts. RESULTS Key concepts included: (1) CPD has changed the way that narrative documentation is used in clinical settings to include more communication functions, strategies to establish joint action in both negative and positive ways; (2) functionality added to CPD to increase the efficiency of input may have increased the efficiency of CPD to support shared situation models, joint and action and the establishment of common ground; (3) new usage of CPD may increase tensions between clinical and administrative roles as the role of narrative is re-defined. CONCLUSIONS This study demonstrates how socio-technical systems co-evolve to support essential human function of coordination and collaboration. Users adapted the system in unique and useful ways that provide insight to future development.
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Affiliation(s)
- Charlene R Weir
- Geriatric Research, Education, and Clinical Center (GRECC), George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA.
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Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011; 18:181-6. [PMID: 21233086 DOI: 10.1136/jamia.2010.007237] [Citation(s) in RCA: 226] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.
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Affiliation(s)
- S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Poor Quality or Poor Design? A Review of the Literature on the Quality of Documentation Within the Electronic Medical Record (Paper Presentation). Comput Inform Nurs 2008. [DOI: 10.1097/01.ncn.0000304829.54886.59] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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