Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators: Table 1

Abstract

ObjectiveClinical 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.MethodsWe 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.ResultsFive 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.ConclusionsCPD 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CPD systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated ‘paper-chart’ paradigm.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.

A Qualitative Analysis Evaluating The Purposes And Practices Of Clinical Documentation

“…While it has been previously shown that providers believe that there is positive value in using CBD tools for documentation, successful adoption of CBD tools still depends largely on how the tools are implemented [7]. Consistent with findings by Embi et al [10], we found that the note serves as an important form of communication between all stakeholders and there are existing concerns surrounding issues of integrating documentation practices with both provider and administrator workflows. Current development of CBD systems has focused on using structured data entry to facilitate data extraction and communication between multiple parties involved in the care of a patient.…”

“…The goal of this study was to expose the knowledge, beliefs and perceptions healthcare providers and administrators have about the value of clinical documentation and the process of documenting. Clinical documentation is a practice that is inextricably shared by both clinical and administrative workflows [10]. To better understand how clinical documentation methods could effectively serve both those who primarily generate notes and those who must review them in today's increasingly multidisciplinary approach to healthcare, we sought perspectives from both healthcare providers and administrators.…”

Clinical Research Informatics and Electronic Health Record Data

“…For example, medication usage can be identified using electronic orders, pharmacy fulfillment, administration records, or medication reconciliation. EHR data are inherently subject to the institution's workflows and data-generating activities [43][44][45]. For research to be reproducible and for results to be valid, the source and limitations of different types of data within an organization must be clearly defined.…”

MedSTS: a resource for clinical semantic textual similarity

“…While the use of EHRs has led to an improvement in quality of healthcare, it has introduced new challenges (Kuhn, Basch et al 2015). One such challenge, ironically, stems from the ease of use of EHRs; the growing use of copy-and-paste, templates, and smart phrases causes clinical notes to bloat in size with poorly organized or erroneous documentation (Embi, Weir et al 2013, Zhang, Pakhomov et al 2014. EHRs are effectively optimized to store massive amounts of information at the cost of adding to the cognitive burden of tracking multiple complex medical problems or maintaining continuity and quality of the clinical decision-making process.…”