Efficiency strategies for facilitating computerized clinical documentation in ambulatory care

Jason J. Saleem, Stephanie Adams, Richard M. Frankel, Bradley N. Doebbeling, Emily S. Patterson

Research output: Chapter in Book/Report/Conference proceedingConference contribution

2 Scopus citations

Abstract

Most providers have experienced increased documentation demands with the use of electronic health records (EHRs). We sought to identify efficiency strategies that providers use to complete clinical documentation tasks in ambulatory care. Two observers performed ethnographic observations and interviews with 22 ambulatory care providers in a U.S. Veterans Affairs Medical Center. Observation notes and interview transcripts were coded for recurrent strategies relating to completion of the EHR progress notes. Findings included: the use of paper artifacts for handwritten notations; electronic templates for automation of certain parts of the note; use of shorthand and phrases rather than narrative writing; copying and pasting from previous EHR notes; directly entering information into the EHR note during the patient encounter; reliance on memory; and pre-populating an EHR note prior to seeing the patient. We discuss the findings in the context of distributed cognition to understand how clinical information is propagated and represented toward completion of a progress note. The study findings have important implications for improving and streamlining clinical documentation related to human factors workload management strategies.

Original languageEnglish (US)
Title of host publicationMEDINFO 2013 - Proceedings of the 14th World Congress on Medical and Health Informatics
PublisherIOS Press
Pages13-17
Number of pages5
Edition1-2
ISBN (Print)9781614992882
DOIs
StatePublished - Jan 1 2013
Externally publishedYes
Event14th World Congress on Medical and Health Informatics, MEDINFO 2013 - Copenhagen, Denmark
Duration: Aug 20 2013Aug 23 2013

Publication series

NameStudies in Health Technology and Informatics
Number1-2
Volume192
ISSN (Print)0926-9630
ISSN (Electronic)1879-8365

Other

Other14th World Congress on Medical and Health Informatics, MEDINFO 2013
CountryDenmark
CityCopenhagen
Period8/20/138/23/13

Keywords

  • Clinical documentation
  • Electronic health records
  • Human factors
  • Workflow
  • Workload

ASJC Scopus subject areas

  • Biomedical Engineering
  • Health Informatics
  • Health Information Management

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  • Cite this

    Saleem, J. J., Adams, S., Frankel, R. M., Doebbeling, B. N., & Patterson, E. S. (2013). Efficiency strategies for facilitating computerized clinical documentation in ambulatory care. In MEDINFO 2013 - Proceedings of the 14th World Congress on Medical and Health Informatics (1-2 ed., pp. 13-17). (Studies in Health Technology and Informatics; Vol. 192, No. 1-2). IOS Press. https://doi.org/10.3233/978-1-61499-289-9-13