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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    • "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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    • "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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