Leveraging systems thinking to design patient-centered clinical documentation systems (original) (raw)

Efficiency strategies for facilitating computerized clinical documentation in ambulatory care

Studies in health technology and informatics

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 cli...

Use of Electronic Health Record Documentation by Healthcare Workers in an Acute Care Hospital System

Journal of Healthcare Management, 2014

Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this information is used for patient care, and the amount of time clinicians perceive they review and document information in the EHR. A survey administered at a large, multisite healthcare system was used to gather this information. Findings show that diagnostic results and physician documents are viewed more often than documentation by nurses and ancillary caregivers. Most clinicians use the information in the EHR to understand the patient's overall condition, make clinical decisions, and communicate with other caregivers. The majority of respondents reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with much of this time spent completing detailed forms seldom viewed by others. Various flow sheets and forms within the EHR are rarely viewed. Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation. New forms and input fields should be added sparingly and in collaboration with informatics staff and clinical team members to determine the most useful information when developing documentation systems.

Electronic Bedside Documentation and Nurse-Patient Communication: A Dissertation

2014

The Institute of Medicine (2011b) stated that health information technology will change the fundamental way that nurses document patient care. Nurses should become less task orientated and have more opportunities to communicate with and support their patients and their patients' families (Institute of Medicine, 2011b). However, as indicated by the investigators in the study (2011b) and Spencer and Lunsford (2010), little is known about nurse-patient communication that takes place during electronic documentation at the bedside. Findings from the studies by Timmons (2003), Kossman and Scheidenhelm (2008), and Duffy, Kharasch, and Du (2010) suggested that when nurses use electronic documentation, the communication between the nurses and the patients is not dynamic. There is no give and take between the nurse and the patient. The nurse carries out an action automatically, without any discussion or input from the patient. Patients' acknowledgment that their needs are either still present, not improved, or resolution is limited. Moreover, Kossman and Scheidenhelm (2008) suggested that electronic documentation creates task driven give and take communication between the nurse and the patient, and that communication is based on marking off an electronic checkbox. The participants (N = 46) reported that their attention was diverted away from the patient and toward the computer (Kossman & Scheidenhelm, 2008). ELECTRONIC DOCUMENTATION 9 The purpose of this study was to explore the culture of nurse-patient interaction associated with electronic documentation at the bedside. The specific aims of this study were: 1) to describe nurse-patient interaction as demonstrated in verbal and non-verbal reciprocal communication; 2) to identify the emerging overt and unspoken patterns of nurse-patient communication while using electronic documentation; and 3) to identify nurses' actions, either automatic (without discussing with the patient) or deliberative (involving reciprocal communication with the patient), that occur while integrating electronic bedside documentation into patient care. The study design was micro-ethnography. The primary modes of data collection were passive participant observation, audio recording of the nurse-patient interactions, and interviews, both informal and semi-structured. This study added to knowledge about nursing practice and electronic documentation at the bedside, the environment of that bedside practice, and nurse-patient communication as it is occurred in real time. The following text provides context of health information technology. The concepts of nurse-patient interaction without electronic documentation are examined. Also, nurse-patient interactions and nurses' perception of the care provided with respect to bedside electronic documentation are examined. Health Information Technology Background The move from paper to computerized documentation is projected to improve hospitalized patient outcomes while decreasing the cost of care. The impetus for this major change originated from a national interest in improving health care safety. Brennan, et al. (1991) suggested that patient safety was compromised as the direct result of failures of medical management and substandard care. Examples of suboptimal care were illustrated in the Institute of Medicine Report (IOM), Too Err is Human: Building a Safer Health System (2000). The

Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care

Electronic health records are expected to improve the quality of care provided to hospitalized patients. For nurses, use of electronic documentation sources becomes highly relevant because this is where they obtain the majority of necessary patient information. Methods: An integrative review of the literature examined the relationship between electronic nursing documentation and the quality of care provided to hospitalized patients. Donabedian's quality framework was used to organize empirical literature for review. Results: To date, the use of electronic nursing documentation to improve patient outcomes remains unclear. Conclusions and Implications: Future research should investigate the daytoday interactions between nurses and electronic nursing documentation for the provision of quality care to hospitalized patients.

Use of electronic clinical documentation: time spent and team interactions

Journal of the American Medical Informatics Association, 2011

Objective To measure the time spent authoring and viewing documentation and to study patterns of usage in healthcare practice. Design Audit logs for an electronic health record were used to calculate rates, and social network analysis was applied to ascertain usage patterns. Subjects comprised all care providers at an urban academic medical center who authored or viewed electronic documentation. Measurement Rate and time of authoring and viewing clinical documentation, and associations among users were measured. Results Users spent 20e103 min per day authoring notes and 7e56 min per day viewing notes, with physicians spending less than 90 min per day total. About 16% of attendings' notes, 8% of residents' notes, and 38% of nurses' notes went unread by other users, and, overall, 16% of notes were never read by anyone. Viewing of notes dropped quickly with the age of the note, but notes were read at a low but measurable rate, even after 2 years. Most healthcare teams (77%) included a nurse, an attending, and a resident, and those three users' groups were the first to write notes during an admission. Limitations The limitations were restriction to a single academic medical center and use of log files without direct observation. Conclusions Care providers spend a significant amount of time viewing and authoring notes. Many notes are never read, and rates of usage vary significantly by author and viewer. While the rate of viewing a note drops quickly with its age, even after 2 years inpatient notes are still viewed.

Use of a human factors approach to uncover informatics needs of nurses in documentation of care

International Journal of Medical Informatics, 2013

Nursing informatics Workflow Electronic health records Information systems a b s t r a c t Purpose: The success of health information technology implementations is often tied to the impact the technical system will have on the work of the clinicians using them. Considering the role of nurses in healthcare, it is shocking that there is a lack of evaluations of nursing information systems in the literature. Here we report on how a human factors approach can be used to address barriers and facilitators to use of the nursing information system (NIS).

Health Care Documentation Management in Hospital Conditions

Journal of applied health sciences, 2020

Healthcare documentation or nursing documentation as often used in practice is the name of an indispensable part of a patient’s medical documentation, and documentation is an integral part of a nurse’s daily work. Documenting health care in the hospital means recording data on all procedures performed, during the entire health care process for the individual, all for the purpose of systematic monitoring, planning and evaluation of the quality of health care. Nursing documentation serves as a means of communication between the team and is of great importance for the quality and continuity of health care. AIMS: 1 - To determine the existence of health care documentation in hospital health care institutions; 2 - Examine the importance and purpose of documenting health care among nurses-medical technicians; 3 - Examine the practice of nurses-medical technicians in the process of administering health care; 4 - Present quality indicators that are monitored and analyzed through health care...

Literature review on patient-friendly documentation systems

2006

Description: English medical, intensive care data From http://i3p-class.itc.it/projects\_scheda.asp?id=14: "MAGIC is an intelligent multimedia presentation system for the medical domain. After a patient has heart surgery, the physicians in the operating room (or) must inform the caregivers in the intensive care unit (icu) what happened during the surgery in order to prepare for the patient when he/she arrives in the ICU. MAGIC replaces the OR physicians in this scenario by presenting similar information using coordinated text, speech and graphics." Research Focus: Integration and coordination of graphics, speech and text. Evaluation.

Cognitive factors influencing perceptions of clinical documentation tools

Journal of Biomedical Informatics, 2007

Identifying healthcare providers' perceptions of clinical documentation methods can inform the design of computer-based documentation tools. The authors investigated the cognitive factors underlying such perceptions by performing a qualitative analysis that included open-ended in-depth interviews of a convenience sample of healthcare providers who use a variety of documentation methods. A total of 16 providers participated in the study; subjects included physicians and nurse practitioners from medical and surgical specialties who used paper-and computer-based documentation tools. Based on interview data, authors identified five factors that influenced satisfaction with clinical documentation tools: document system time efficiency, availability, expressivity, structure, and quality. These factors, if validated by subsequent investigations, can be used to develop a formal conceptual model of providers' perceptions of their satisfaction with various documentation systems.