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DOI: 10.4338/ACI-2012-02-CR-0003
Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital
Correspondence to:
Publication History
received:
05 March 2012
accepted:
23 April 2012
Publication Date:
16 December 2017 (online)
Summary
Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children’s Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.
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Keywords
Electronic health records - information storage and retrieval - physician’s practice patterns - software design - time factors - user-computer interface - documentation
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Conflicts of interest
The authors declare that we have no conflicts of interest in the research.
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References
- 1 Ash JS, Bates DW. Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion. J Am Med Inform Assoc 2005; 12 (01) 8-12.
- 2 Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress report on electronic health records in U. S. hospitals. Health Aff (Millwood) 2010; 29 (010) 1951-1957.
- 3 Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood) 2011; 30 (03) 464-471.
- 4 Longhurst CA, Parast L, Sandborg CI, Widen E, Sullivan J, Hahn JS. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics 2010; 126 (01) 14-21.
- 5 Payne TH, tenBroek AE, Fletcher GS, Labuguen MC. Transition from paper to electronic inpatient physician notes. J Am Med Inform Assoc 2010; 17 (01) 108-111.
- 6 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11 (02) 104-112.
- 7 Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc 2004; 11 (04) 300-309.
- 8 Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011; 18 (02) 181-186.
- 9 EMR Adoption Model.. HIMSS Analytics;. 2012 [cited 2012 January 20]; Available from:www.himssana lytics.org/hc_providers/emr_adoption.asp.
- 10 McCoy MJ, Diamond AM, Strunk AL. Special requirements of electronic medical record systems in obstetrics and gynecology. Obstet Gynecol 2010; 116 (01) 140-143.
- 11 Rosenbloom ST, Crow AN, Blackford JU, Johnson KB. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform 2007; 40 (02) 106-113.
- 12 O’Donnell HC, Kaushal R, Barron Y, Callahan MA, Adelman RD, Siegler EL. Physicians’ attitudes towards copy and pasting in electronic note writing. J Gen Intern Med 2009; 24 (01) 63-68.
- 13 Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA 2006; 295 (020) 2335-2336.
- 14 Wrenn JO, Stein DM, Bakken S, Stetson PD. Quantifying clinical narrative redundancy in an electronic health record. J Am Med Inform Assoc 2010; 17 (01) 49-53.
- 15 Bernstam EV, Hersh WR, Sim I, Eichmann D, Silverstein JC, Smith JW. et al. Unintended consequences of health information technology: a need for biomedical informatics. J Biomed Inform 2010; 43 (05) 828-830.
- 16 Payne TH, Kalus R, Zehner J. Evolution and use of a note classification scheme in an electronic medical record. AMIA Annu Symp Proc 2005: 599-603.
- 17 Rosenbloom ST, Stead WW, Denny JC, Giuse D, Lorenzi NM, Brown SH. et al. Generating Clinical Notes for Electronic Health Record Systems. Appl Clin Inform 2010; 1 (03) 232-243.
- 18 Hartzband P, Groopman J. Off the record –avoiding the pitfalls of going electronic. N Engl J Med 2008; 358 (016) 1656-1658.
- 19 Feblowitz JC, Wright A, Singh H, Samal L, Sittig DF. Summarization of clinical information: a conceptual model. J Biomed Inform 2011; 44 (04) 688-699.
- 20 Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278 (011) 593-600.
Correspondence to:
-
References
- 1 Ash JS, Bates DW. Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion. J Am Med Inform Assoc 2005; 12 (01) 8-12.
- 2 Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress report on electronic health records in U. S. hospitals. Health Aff (Millwood) 2010; 29 (010) 1951-1957.
- 3 Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood) 2011; 30 (03) 464-471.
- 4 Longhurst CA, Parast L, Sandborg CI, Widen E, Sullivan J, Hahn JS. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics 2010; 126 (01) 14-21.
- 5 Payne TH, tenBroek AE, Fletcher GS, Labuguen MC. Transition from paper to electronic inpatient physician notes. J Am Med Inform Assoc 2010; 17 (01) 108-111.
- 6 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11 (02) 104-112.
- 7 Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc 2004; 11 (04) 300-309.
- 8 Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011; 18 (02) 181-186.
- 9 EMR Adoption Model.. HIMSS Analytics;. 2012 [cited 2012 January 20]; Available from:www.himssana lytics.org/hc_providers/emr_adoption.asp.
- 10 McCoy MJ, Diamond AM, Strunk AL. Special requirements of electronic medical record systems in obstetrics and gynecology. Obstet Gynecol 2010; 116 (01) 140-143.
- 11 Rosenbloom ST, Crow AN, Blackford JU, Johnson KB. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform 2007; 40 (02) 106-113.
- 12 O’Donnell HC, Kaushal R, Barron Y, Callahan MA, Adelman RD, Siegler EL. Physicians’ attitudes towards copy and pasting in electronic note writing. J Gen Intern Med 2009; 24 (01) 63-68.
- 13 Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA 2006; 295 (020) 2335-2336.
- 14 Wrenn JO, Stein DM, Bakken S, Stetson PD. Quantifying clinical narrative redundancy in an electronic health record. J Am Med Inform Assoc 2010; 17 (01) 49-53.
- 15 Bernstam EV, Hersh WR, Sim I, Eichmann D, Silverstein JC, Smith JW. et al. Unintended consequences of health information technology: a need for biomedical informatics. J Biomed Inform 2010; 43 (05) 828-830.
- 16 Payne TH, Kalus R, Zehner J. Evolution and use of a note classification scheme in an electronic medical record. AMIA Annu Symp Proc 2005: 599-603.
- 17 Rosenbloom ST, Stead WW, Denny JC, Giuse D, Lorenzi NM, Brown SH. et al. Generating Clinical Notes for Electronic Health Record Systems. Appl Clin Inform 2010; 1 (03) 232-243.
- 18 Hartzband P, Groopman J. Off the record –avoiding the pitfalls of going electronic. N Engl J Med 2008; 358 (016) 1656-1658.
- 19 Feblowitz JC, Wright A, Singh H, Samal L, Sittig DF. Summarization of clinical information: a conceptual model. J Biomed Inform 2011; 44 (04) 688-699.
- 20 Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278 (011) 593-600.