Use of electronic clinical documentation: Time spent and team interactions

Department of Biomedical Informatics, Columbia University Medical Center, New York, USA.
Journal of the American Medical Informatics Association (Impact Factor: 3.5). 02/2011; 18(2):112-7. DOI: 10.1136/jamia.2010.008441
Source: PubMed


To measure the time spent authoring and viewing documentation and to study patterns of usage in healthcare practice.
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.
Rate and time of authoring and viewing clinical documentation, and associations among users were measured.
Users spent 20-103 min per day authoring notes and 7-56 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.
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.

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    • "Clinical documentation is a core activity for physicians, nurses, and other healthcare professionals and accounts for a substantial portion of a clinician's workday [1] [2] [3] [4]. One study demonstrated that nearly as much time was spent on documentation as was spent on direct patient care [5]. "
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    ABSTRACT: 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.
    Studies in health technology and informatics 08/2013; 192(1):13-7. DOI:10.3233/978-1-61499-289-9-13
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    • "Moreover, replicated erroneous information in clinical notes has been demonstrated to create medical errors and be a patient safety issue [1]. It has also been reported that redundant information in notes results in decreased use of clinical notes by clinicians [3]. Healthcare organizations are increasingly recognizing the issues caused by redundant information in electronic notes and are asking for solutions [4]. "
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    ABSTRACT: Automated methods to detect new information in clinical notes may be valuable for navigating and using information in these documents for patient care. Statistical language models were evaluated as a means to quantify new information over longitudinal clinical notes for a given patient. The new information proportion (NIP) in target notes decreased logarithmically with increasing numbers of previous notes to create the language model. For a given patient, the amount of new information had cyclic patterns. Higher NIP scores correlated with notes having more new information often with clinically significant events, and lower NIP scores indicated notes with less new information. Our analysis also revealed "copying and pasting" to be widely used in generating clinical notes by copying information from the most recent historical clinical notes forward. These methods can potentially aid clinicians in finding notes with more clinically relevant new information and in reviewing notes more purposefully which may increase the efficiency of clinicians in delivering patient care.
    Studies in health technology and informatics 08/2013; 192(1):754-8. DOI:10.3233/978-1-61499-289-9-754
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    • "While the majority of literature in this area discusses the impact on nurses work in the inpatient setting, our study highlights the impact HIT can have on time efficiency of nurses in an outpatient chronic disease setting. Nurses in general spend a large amount of time documenting [31] and so it is important to understand how HIT affects this, particularly if it allows more time for nurses to devote their attention to direct patient care. While results from previous studies are mixed concerning the changes in time nurses spend in documentation and direct patient care when using HIT [19] [20] [32], our findings support those studies which demonstrate a reduction in the time nurses spent on documentation and an increase in direct and indirect patient care time, a purported benefit of HIT. "
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    ABSTRACT: Objective: To evaluate the impact of an electronic drug monitoring system (eDMS) for ambulatory rheumatology patients on time nurses spent on, and the process of, drug monitoring. Methods: The study was conducted in the Rheumatology Department of a large metropolitan hospital. The eDMS, a module of the Hospital Clinical Information System (HCIS), was designed to allow electronic ordering and subsequent monitoring of ambulatory patients on long-term, immunosuppressive rheumatology medications. Quantitative measures collected before and after the intervention were: time spent on specific nursing activities; who nurses spent time with; format and location of documentation monitoring; and patient throughput. Qualitative data from interviews and observations were collected to ascertain the impact of the eDMS on nurses' monitoring activities. Results: Nurses spent significantly less time on medication monitoring tasks (33.1% versus 26.4%, P=0.003) and significantly more time on patient care (6.5-18.1%, P<0.0001) following implementation of the eDMS. Nurses also spent significantly more time with patients (7.7-19.8%, P<0.0001) and relatives (0.4-3.7%, P=0.01) after the system was implemented. The time saved on monitoring allowed the number of nurse directed clinics and patient throughput to increase following eDMS implementation. Qualitative data supported results from the timing study with nurses reporting that the monitoring process was more standardised, safer, took less time and simplified documentation. Conclusions: The eDMS was associated with a reduction in time spent on the complex task of medication monitoring allowing nurses to spend a greater proportion of their time on other patient care activities.
    International Journal of Medical Informatics 12/2012; 82(3). DOI:10.1016/j.ijmedinf.2012.11.009 · 2.00 Impact Factor
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