Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department

Abstract

Objective The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework. Materials and Methods In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system. Results Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record. Discussion Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses. Conclusion Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

Consumer Health Informatics for Racial and Ethnic Minoritized Communities: Minor Progress, Major Opportunities

“…Similarly, body mapping can be used with community members to explore how to broader contextual factors shape health [35]. Other suggested methods include systems mapping [36], observations (including participant observation) [37], photo elicitation [38], and task analysis [39]. Mixed methods approaches should be incorporated to produce a comprehensive view of the topic being studied as well as to triangulate findings.…”

Impact of a digital care logistics system on care duration, consumer satisfaction and shift leaders' workload in emergency departments

“…A longitudinal prospective design was used. ED work processes are complex and they cannot be measured with a single data point or by one statistical method but need to be explored from a combination of data gathered with multiple methods, and therefore, a sociotechnical systems framework and a mixed-methods approach have been suggested for implementing larger information technology projects [33]. Also, a longer-term fol-low-up on the effects of system implementation is recommended as a systematic review indicated that EHR system implementation first increased documentation time, but as staff become more familiar with the system it ultimately improved work flow [13].…”