Efficiency Strategies for Facilitating Computerized Clinical Documentation in Ambulatory Care

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 clinical information is propagated and represented toward completion of a progress note. The study findings have important implications for improving and streamlining clinical documentation related to human factors workload management strategies

The Promise of Health Information Technology: Ensuring that Florida's Children Benefit

Substantial policy interest in supporting the adoption of Health Information Technology (HIT) by the public and private sectors over the last 5 -- 7 years, was spurred in particular by the release of multiple Institute of Medicine reports documenting the widespread occurrence of medical errors and poor quality of care (Institute of Medicine, 1999 & 2001). However, efforts to focus on issues unique to children's health have been left out of many of initiatives. The purpose of this report is to identify strategies that can be taken by public and private entities to promote the use of HIT among providers who serve children in Florida

Methods to Facilitate the Capture, Use, and Reuse of Structured and Unstructured Clinical Data.

Electronic health records (EHRs) have great potential to improve quality of care and to support clinical and translational research. While EHRs are being increasingly implemented in U.S. hospitals and clinics, their anticipated benefits have been largely unachieved or underachieved. Among many factors, tedious documentation requirements and the lack of effective information retrieval tools to access and reuse data are two key reasons accounting for this deficiency. In this dissertation, I describe my research on developing novel methods to facilitate the capture, use, and reuse of both structured and unstructured clinical data. Specifically, I develop a framework to investigate potential issues in this research topic, with a focus on three significant challenges. The first challenge is structured data entry (SDE), which can be facilitated by four effective strategies based on my systematic review. I further propose a multi-strategy model to guide the development of future SDE applications. In the follow-up study, I focus on workflow integration and evaluate the feasibility of using EHR audit trail logs for clinical workflow analysis. The second challenge is the use of clinical narratives, which can be supported by my innovative information retrieval (IR) technique called “semantically-based query recommendation (SBQR)”. My user experiment shows that SBQR can help improve the perceived performance of a medical IR system, and may work better on search tasks with average difficulty. The third challenge involves reusing EHR data as a reference standard to benchmark the quality of other health-related information. My study assesses the readability of trial descriptions on ClinicalTrials.gov and found that trial descriptions are very hard to read, even harder than clinical notes. My dissertation has several contributions. First, it conducts pioneer studies with innovative methods to improve the capture, use, and reuse of clinical data. Second, my dissertation provides successful examples for investigators who would like to conduct interdisciplinary research in the field of health informatics. Third, the framework of my research can be a great tool to generate future research agenda in clinical documentation and EHRs. I will continue exploring innovative and effective methods to maximize the value of EHRs.PHDInformationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/135845/1/tzuyu_1.pd

The Electronic Health Record Scorecard: A Measure of Utilization and Communication Skills

As the adoption rate of electronic health records (EHRs) in the United States continues to grow, both providers and patients will need to adapt to the reality of a third actor being present during the visit encounter. The purpose of this project is to provide insight on “best” practice patterns for effective communication and efficient use of the EHR in the clinical practice setting. Through the development of a comprehensive scorecard, this project assessed current status of EHR use and communication skills among health care providers in various clinical practice settings. Anticipated benefits of this project are increased comfortability in interfacing with the EHR and increased satisfaction on the part of the provider as well as the patient. Serving as a benchmark, this assessment has the potential to help guide future health information technology development, training, and education for both students and health care providers

Performance Measures Using Electronic Health Records: Five Case Studies

Presents the experiences of five provider organizations in developing, testing, and implementing four types of electronic quality-of-care indicators based on EHR data. Discusses challenges, and compares results with those from traditional indicators

Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department

Introduction: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the mid- and low-acuity zones of an academic emergency department (ED) with and without medical scribes.Methods: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition.Results: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI], -17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI, -6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted.Conclusion: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation

Using Clinical Decision Support to Maintain Medication and Problem Lists: A Pilot Study to Yield Higher Patient Safety

To Investigate Whether Clinical Decision Support that Automates the Matching of Ordered Drugs to Problems (Clinical Diagnoses) on the Problem List Can Enhance the Maintenance of Both Medication and Problem Lists in the Electronic Medical Record, We Designed a Clinical Decision Support System to Match Ordered Drugs on the Medication List and Ongoing Problems on the Problem List. We Evaluated the Capability and Performance of This Clinical Decision Support System in Medication-Problem Matching using Physician Expert Chart Audits to Match Ordered Drugs to Ongoing Clinical Problems. a Clinical Decision Support System Was Shown to Be Useful in Improving Medication-Problem Matches in 140 Randomly Selected Audited Patient Encounters in Three Inpatient Units. Enhanced Maintenance of Both the Medication and Problem Lists Can Permit the Exploitation of Advanced Decision Support Strategies that Yield Higher Patient Safety. © 2008 IEEE

Educating Nurses on Workflow Changes from Electronic Health Record Adoption

Workflow issues related to adoption of the electronic health record (EHR) has led to unsafe workarounds, decreased productivity, inefficient clinical documentation and slow rates of EHR adoption. The problem addressed in this quality improvement project was nurses\u27 lack of knowledge about workflow changes due to EHR adoption. The purpose of this project was to identify changes in workflow and to develop an educational module to communicate the changes. This project was guided by both the ADDIE model (analysis, design, development, implementation, and evaluation) and the diffusion of innovations theory. Five stages were involved: process mapping, cognitive walkthrough, eLearning module development, pilot study, and evaluation. The process maps and cognitive walkthrough revealed significant workflow changes particularly in clinical practice guidelines, emergency department treatment plan, and the interdisciplinary care plan. The eLearning module was developed to describe workflow changes using gamification, scenario-based learning, and EHR simulation. The 14-item course evaluation included a 6-point Likert scale and closed- and open-ended questions. A purposive sample of nurses (N = 30) from the emergency department and inpatient care areas were invited to complete the eLearning module and course evaluation. Data were collected until saturation was achieved (n = 15). Descriptive statistics revealed the participants\u27 positive learning experience. This quality improvement project is expected to contribute to positive social change by facilitating the effective use of the new EHR which can improve the quality of patient care, promote patient safety, reduce healthcare costs, and improve patient outcomes

Health Information Technology in the United States, 2008

Provides updated survey data on health information technology (HIT) and electronic health records adoption, with a focus on providers serving vulnerable populations. Examines assessments of HIT's effect on the cost and quality of care and emerging issues