Involving Health Care Professionals in the Development of Electronic Health Records: Scoping Review

Busse, Theresa Sophie; Jux, Chantal; Laser, Johannes; Rasche, Peter; Vollmar, Horst Christian; Ehlers, Jan P.; Kernebeck, Sven

doi:10.2196/45598

Cited by 3 publications

(1 citation statement)

References 148 publications

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“…These finding came organically from the codesign open forum and there is increasing awareness of the value that codesign brings to digital health technology development. 30 Given these findings, it is possible that previous efforts to standardise referral forms have failed because without codesign, referral forms tend towards being longer, more complex and request information that referring providers do not have or is better collected directly from patients. The next step from this study is to further implement the codesigned referral form in clinical practice.…”

Section: Discussionmentioning

confidence: 99%

Codesigned standardised referral form: simplifying the complexity

Laing,

Jarmain,

Elliott

et al. 2024

BMJ Health Care Inform

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BackgroundReferring providers are often critiqued for writing poor-quality referrals. This study characterised clinical referral guidelines and forms to understand which data consultant providers require. These data were then used to codesign an evidence-based, high-quality referral form.MethodsThis study used both observational and quality improvement approaches. Canadian referral guidelines were reviewed and summarised. Referral data fields from 150 randomly selected Ontario referral forms were categorised and counted. The referral guideline summary and referral data were then used by referring providers, consultant providers and administrators to codesign a referral form.ResultsReferral guidelines recommended 42 types of referral data be included in referrals. Referral data were categorised as patient demographics, provider demographics, reason for referral, clinical information and administrative information. The percentage of referral guidelines recommending inclusion of each type of referral data varied from 8% to 77%. Ontario referral forms requested 264 different types of referral data. Digital referral forms requested more referral data types than paper-based referral forms (55.0±10.6 vs 30.5±8.1; 95% CI p<0.01). A codesigned referral form was created across two sessions with 29 and 21 participants in each.DiscussionReferral guidelines lack consistency and specificity, which makes writing high-quality referrals challenging. Digital referral forms tend to request more referral data than paper-based referrals, which creates administrative burdens for referring and consultant providers. We created the first codesigned referral form with referring providers, consultant providers and administrators. We recommend clinical adoption of this form to improve referral quality and minimise administrative burdens.

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Section: Discussionmentioning

confidence: 99%

Codesigned standardised referral form: simplifying the complexity

Laing,

Jarmain,

Elliott

et al. 2024

BMJ Health Care Inform

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Nurse-centered co-design of an electronic health record nursing summary

Park,

Marquard

2024

Human Factors in Healthcare

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Structural and Process Factors Influencing Documentation Practice in Private and Public Labour Wards of Parirenyatwa Maternity Hospital, Zimbabwe

Mutema,

Haruzivish,

Mhlanga

2024

AJNS

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Background: Documentation is crucial for evidence-based nursing. Proper documentation ensures effective communication and quality patient care, while poor documentation compromises care. This study compared structural and process factors affecting documentation quality and patient outcomes in private and public labor wards at Parirenyatwa Mbuya Nehanda Maternity Hospital (MNMH). Methods: A multiple methods approach was used. A total of 177 records were assessed for quality documentation, and 10 midwives were observed on practice documentation. Additionally, 116 interviews were conducted with midwives to elicit information on documentation practices. Data was collected and quantitative data was analyzed using Statistical Package for Social Sciences version (SPSS version 20). Qualitative data was manually analysed and thematic analysis was used to generate codes and themes. Quantitative data was presented in tables, graphs, as frequencies and percentages while qualitative data was presented in narrative form. Results: With regards to structural factors, being in a public labour ward was significantly associated with increased the likelihood of higher nurse to patient ratio compared to being in a private labour ward (p=0.002). No process indicator was significantly associated with the type of labour. Those in the public labour ward were more likely to have complications and admitted in (Neonatal Intensive Care Unit) NICU (p=0.008). Conclusion: The study determined that there was poor documentation practice in both public and private labour wards. Though there was a high level of awareness of critical aspects of labour to document and the importance of documentation by midwives from both wards, this did not necessarily translate to practice. There is a need to also formulate standard operating protocols and guidelines to guide and standardize documentation at MNMH.

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Involving Health Care Professionals in the Development of Electronic Health Records: Scoping Review

Cited by 3 publications

References 148 publications

Codesigned standardised referral form: simplifying the complexity

Codesigned standardised referral form: simplifying the complexity

Nurse-centered co-design of an electronic health record nursing summary

Structural and Process Factors Influencing Documentation Practice in Private and Public Labour Wards of Parirenyatwa Maternity Hospital, Zimbabwe

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