Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes

March, Christopher A.; Scholl, Gretchen; Dversdal, Renee K.; Richards, Matthew; Wilson, Leah M.; Mohan, Vishnu; Gold, Jeffrey A.

doi:10.4300/jgme-d-15-00201.1

Cited by 26 publications

(22 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Even more interesting was the difference in actual “note” elements between scribes. This is consistent with findings from studies showing discrepancies between physicians in the content and quality of documentation in notes [ 19 , 20 ]. Thus, whereas this phenomenon is most likely not unique to scribes, it does imply that scribes may face the same issues that are found among other clinicians.…”

Section: Discussionsupporting

confidence: 92%

Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study

et al. 2017

Self Cite

View full text Add to dashboard Cite

BackgroundThe increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes.ObjectiveThe objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes’ transcribed notes in the EHR.MethodsFrom a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy.ResultsAll scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%.ConclusionsWe created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency.

show abstract

Section: Discussionsupporting

confidence: 92%

Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study

et al. 2017

Self Cite

View full text Add to dashboard Cite

show abstract

“…Feedback efforts, therefore, while highly emphasized in medical education, may fail if they lack such contextual credibility. For example, March, et al (2016) showed a wide variability in intern's clinical documentation even when using a simulated exercise that closely approximated clinical care [12]. In keeping with the behaviors of complex adaptive systems, perhaps our intervention fell short due to the residents' relatively low perceived importance associated with clinical documentation, the many competing demands on trainee time, and minimal incentive to create documentation that is accurate and of high quality.…”

Section: Lessons Learnedmentioning

confidence: 93%

Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record

Fanucchi¹,

Yan²,

Conigliaro³

2016

Appl Clin Inform

View full text Add to dashboard Cite

SummaryBackground: Communication errors are identified as a root cause contributing to a majority of sentinel events. The clinical note is a cornerstone of physician communication, yet there are few published interventions on teaching note writing in the electronic health record (EHR). This is a prospective, two-site, quality improvement project to assess and improve the quality of clinical documentation in the EHR using a validated assessment tool. Methods: Internal Medicine (IM) residents at the University of Kentucky College of Medicine (UK) and Montefiore Medical Center/Albert Einstein College of Medicine (MMC) received one of two interventions during an inpatient ward month: either a lecture, or a lecture and individual feedback on progress notes. A third group of residents in each program served as control. Notes were evaluated with the Physician Documentation Quality Instrument 9 (PDQI-9). Results: Due to a significant difference in baseline PDQI-9 scores at MMC, the sites were not combined. Of 75 residents at the UK site, 22 were eligible, 20 (91%) enrolled, 76 notes in total were scored. Of 156 residents at MMC, 22 were eligible, 18 (82%) enrolled, 40 notes in total were scored. Note quality did not improve as measured by the PDQI-9. Conclusion: This educational quality improvement project did not improve the quality of clinical documentation as measured by the PDQI-9. This project underscores the difficulty in improving note quality. Further efforts should explore more effective educational tools to improve the quality of clinical documentation in the EHR.

show abstract

“…On the other hand, one of the disadvantages attributed to the EHR is that it allows "copy & paste" of previous records, duplicating information and perpetuating possible errors. This functionality has appeared in the literature related to saving time, increasing the efficiency of the process (Al Hadidi et al, 2017;Hartzband and Groopman, 2008;Heiman et al, 2014;Hirschtick, 2006;March et al, 2016;Shoolin et al, 2013). Transcriptions should be made in a conscious and responsible way by health professionals, taking advantage of the positive points for which "copy & paste" was created.…”

Section: Phrs Compared To Ehrsmentioning

confidence: 99%

Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders’ perceptions

Vera

Santos

Pinto

et al. 2019

HIM J

View full text Add to dashboard Cite

Background: Health records are the basis of clinical coding. In Portugal, relevant diagnoses and procedures are abstracted and categorised using an internationally accepted classification system and the resulting codes, together with the administrative data, are then grouped into diagnosis-related groups (DRGs). Hospital reimbursement is partially calculated from the DRGs. Moreover, the administrative database generated with these data is widely used in research and epidemiology, among other purposes. Objective: To explore the perceptions of medical coders (medical doctors) regarding possible problems with health records that may affect the quality of coded data. Method: A qualitative design using four focus groups sessions with 10 medical coders was undertaken between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed from the literature and authors’ expertise. The focus groups sessions were taped, transcribed and analysed to elicit themes. Results: There are several problems, identified by the focus groups, in health records that influence the coded data: the lack of or unclear documented information; the variability in diagnosis description; “copy & paste”; and the lack of solutions to solve these problems. Conclusion and implications: The use of standards in health records, audits and physician awareness could increase the quality of health records, contributing to improvements in the quality of coded data, and in the fulfilment of its purposes (e.g. more accurate payments and more reliable research).

show abstract

Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes

Cited by 26 publications

References 10 publications

Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study

Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study

Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record

Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders’ perceptions

Contact Info

Product

Resources

About