Objective: The objective of this study is to understand physicians' usage of inpatient notes by (i) ascertaining different clinical note-entry and reading/retrieval styles in two different and widely used Electronic Health Record (EHR) systems, (ii) extrapolating potential factors leading to adoption of various note-entry and reading/retrieval styles and (iii) determining the amount of time to task associated with documenting different types of clinical notes. Methods: In order to answer "what" and "why" questions on physicians' adoption of certain-note-entry and reading/retrieval styles, an ethnographic study entailing Internal Medicine residents, with a mixed data analysis approach was performed. Participants were observed interacting with two different EHR systems in inpatient settings. Data was collected around the use and creation of History and Physical (H&P) notes, progress notes and discharge summaries. Results: The highest variability in template styles was observed with progress notes and the least variability was within discharge summaries, while note-writing styles were most consistent for H&P notes. The first sections to be read in a H&P and progress note were the Chief Complaint and Assessment & Plan sections, respectively. The greatest note retrieval variability, with respect to the order of how note sections were reviewed, was observed with H&P and progress notes. Physician preference for adopting a certain reading/retrieval order appeared to be a function of what best fits their workflow while fulfilling the stimulus demands. The time spent entering H&P, discharge summaries and progress notes were similar in both EHRs. Conclusion: This research study unveils existing variability in clinical documentation processes and provides us with important information that could help in designing a next generation EHR Graphical User Interface (GUI) that is more congruent with physicians' mental models, task performance needs, and workflow requirements.
Bibliographical noteFunding Information:
This study was supported by the Agency for Healthcare Research and Quality, Project # R01HS022085 (GM).
We would like to thank the following people for their assistance: Drs. Jessica Voight and Kate Gillen (Chief residents) along with all residents for their participation and valuable feedback, as well as the assistance of Fairview Health Services and the Minneapolis Veterans Affairs Health Care System. We would also like to thank Elizabeth Lindemann in helping us with the proofreading of the manuscript. This study was supported by the Agency for Healthcare Research and Quality, Project # R01HS022085 (GM). The content is solely the responsibility of the authors and does not represent the official views of the Agency for Healthcare Research and Quality.
© 2016 Elsevier Ireland Ltd.
- Clinical documentation
- Electronic health records systems (EHR)
- Graphical User Interface (GUI)
- Human-Computer Interaction (HCI)
- Qualitative analysis