Appl Clin Inform 2014; 05(01): 169-190
DOI: 10.1055/s-0037-1619454
Research Article
Schattauer GmbH

Determining Primary Care Physician Information Needs to Inform Ambulatory Visit Note Display

M.A. Clarke
1  University of Missouri Informatics Institute, University of Missouri
,
L.M. Steege
2  University of Wisconsin-Madison School of Nursing
,
J.L. Moore
1  University of Missouri Informatics Institute, University of Missouri
3  School of Information Science and Learning Technology, University of Missouri
,
R.J. Koopman
4  Department of Family and Community Medicine, University of Missouri
,
J.L. Belden
4  Department of Family and Community Medicine, University of Missouri
,
M.S. Kim
1  University of Missouri Informatics Institute, University of Missouri
5  Department of Health Management and Informatics, University of Missouri
› Author Affiliations
Further Information

Correspondence to:

Min Soon Kim Ph.D.
Assistant Professor
Department of Health Management and Informatics,
University of Missouri
University of Missouri Informatics Institute
CE728 Clinical Support & Education, DC006.00
5 Hospital Drive
Columbia, MO 65212

Publication History

received: 03 September 2013

accepted: 27 February 2013

Publication Date:
20 December 2017 (online)

 

Summary

Background: With the increase in the adoption of electronic health records (EHR) across the US, primary care physicians are experiencing information overload. The purpose of this pilot study was to determine the information needs of primary care physicians (PCPs) as they review clinic visit notes to inform EHR display.

Method: Data collection was conducted with 15 primary care physicians during semi-structured interviews, including a third party observer to control bias. Physicians reviewed major sections of an artificial but typical acute and chronic care visit note to identify the note sections that were relevant to their information needs. Statistical methods used were McNemar-Mosteller’s and Cochran Q.

Results: Physicians identified History of Present Illness (HPI), Assessment, and Plan (A&P) as the most important sections of a visit note. In contrast, they largely judged the Review of Systems (ROS) to be superfluous. There was also a statistical difference in physicians’ highlighting among all seven major note sections in acute (p = 0.00) and chronic (p = 0.00) care visit notes.

Conclusion: A&P and HPI sections were most frequently identified as important which suggests that physicians may have to identify a few key sections out of a long, unnecessarily verbose visit note. ROS is viewed by doctors as mostly “not needed,” but can have relevant information. The ROS can contain information needed for patient care when other sections of the Visit note, such as the HPI, lack the relevant information. Future studies should include producing a display that provides only relevant information to increase physician efficiency at the point of care. Also, research on moving A&P to the top of visit notes instead of having A&P at the bottom of the page is needed, since those are usually the first sections physicians refer to and reviewing from top to bottom may cause cognitive load.

Citation: Clarke MA, Steege LM, Moore JL, Koopman RJ, Belden JL, Kim MS. Determining primary care physician information needs to inform ambulatory visit note display. Appl Clin Inf 2014; 5: 169–190

http://dx.doi.org/10.4338/ACI-2013-08-RA-0064


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Conflicts of interest

The authors declare that they have no conflicts of interest in the research.


Correspondence to:

Min Soon Kim Ph.D.
Assistant Professor
Department of Health Management and Informatics,
University of Missouri
University of Missouri Informatics Institute
CE728 Clinical Support & Education, DC006.00
5 Hospital Drive
Columbia, MO 65212