메뉴 건너뛰기




Volumn 20, Issue 4, 2013, Pages 718-726

Computerized provider documentation: Findings and implications of a multisite study of clinicians and administrators

Author keywords

[No Author keywords available]

Indexed keywords

ADMINISTRATIVE PERSONNEL; ARTICLE; COORDINATION; ELECTRONIC MEDICAL RECORD; FEMALE; HUMAN; INFORMATION PROCESSING; INTERPERSONAL COMMUNICATION; MALE; MEDICAL DOCUMENTATION; MEDICAL INFORMATION; NURSE; PHYSICIAN; WORKFLOW;

EID: 84882787432     PISSN: 10675027     EISSN: 1527974X     Source Type: Journal    
DOI: 10.1136/amiajnl-2012-000946     Document Type: Article
Times cited : (55)

References (52)
  • 1
    • 76149096526 scopus 로고    scopus 로고
    • Launching HITECH
    • Blumenthal D. Launching HITECH. N Engl J Med 2010;362:382-5.
    • (2010) N Engl J Med , vol.362 , pp. 382-385
    • Blumenthal, D.1
  • 2
    • 77956911344 scopus 로고    scopus 로고
    • Health information technology: laying the infrastructure for national health reform
    • Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff (Millwood) 2010;29:1214-19.
    • (2010) Health Aff (Millwood) , vol.29 , pp. 1214-1219
    • Buntin, M.B.1    Jain, S.H.2    Blumenthal, D.3
  • 4
    • 0014413439 scopus 로고
    • Medical records that guide and teach
    • Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:593-600.
    • (1968) N Engl J Med , vol.278 , pp. 593-600
    • Weed, L.L.1
  • 5
    • 0027511203 scopus 로고
    • Introducing physician order entry at a major academic medical center: II
    • Massaro TA. Introducing physician order entry at a major academic medical center: II. Impact on medical education. Acad Med 1993;68:25-30.
    • (1993) Impact on medical education. Acad Med , vol.68 , pp. 25-30
    • Massaro, T.A.1
  • 6
    • 0036715703 scopus 로고    scopus 로고
    • Improving patient safety by identifying side effects from introducing bar coding in medication administration
    • Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc 2002;9:540-53.
    • (2002) J Am Med Inform Assoc , vol.9 , pp. 540-553
    • Patterson, E.S.1    Cook, R.I.2    Render, M.L.3
  • 8
    • 0032813705 scopus 로고    scopus 로고
    • The impact of computerized physician order entry on medication error prevention
    • Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6:313-21.
    • (1999) J Am Med Inform Assoc , vol.6 , pp. 313-321
    • Bates, D.W.1    Teich, J.M.2    Lee, J.3
  • 9
    • 70049091857 scopus 로고    scopus 로고
    • Comparison of time spent writing orders on paper with computerized physician order entry
    • Shu K, Boyle D, Spurr C, et al. Comparison of time spent writing orders on paper with computerized physician order entry. Medinfo 2001;10:1207-11.
    • (2001) Medinfo , vol.10 , pp. 1207-1211
    • Shu, K.1    Boyle, D.2    Spurr, C.3
  • 10
    • 1542327773 scopus 로고    scopus 로고
    • Some unintended consequences of information technology in health care: the nature of patient care information system-related errors
    • 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;11:104-12.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 104-112
    • Ash, J.S.1    Berg, M.2    Coiera, E.3
  • 11
    • 56149108864 scopus 로고    scopus 로고
    • Critical issues in an electronic documentation system
    • Weir CR, Nebeker JR. Critical issues in an electronic documentation system. AMIA Annu Symp Proc 2007:786-90.
    • (2007) AMIA Annu Symp Proc , pp. 786-790
    • Weir, C.R.1    Nebeker, J.R.2
  • 12
    • 0032832052 scopus 로고    scopus 로고
    • Patient care information systems and health care work: a sociotechnical approach
    • Berg M. Patient care information systems and health care work: a sociotechnical approach. Int J Med Inform 1999;55:87-101.
    • (1999) Int J Med Inform , vol.55 , pp. 87-101
    • Berg, M.1
  • 13
    • 3042765729 scopus 로고    scopus 로고
    • Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians
    • Embi PJ, Yackel TR, Logan JR, et al. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc 2004;11:300-9.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 300-309
    • Embi, P.J.1    Yackel, T.R.2    Logan, J.R.3
  • 15
    • 0033258402 scopus 로고    scopus 로고
    • Perceptions of house officers who use physician order entry
    • Ash JS, Gorman PN, Hersh WR, et al. Perceptions of house officers who use physician order entry. Proc AMIA Symp 1999:471-5.
    • (1999) Proc AMIA Symp , pp. 471-475
    • Ash, J.S.1    Gorman, P.N.2    Hersh, W.R.3
  • 16
    • 0034575793 scopus 로고    scopus 로고
    • Multiple perspectives on physician order entry
    • Ash JS, Gorman PN, Lavelle M, et al. Multiple perspectives on physician order entry. Proc AMIA Symp 2000:27-31.
    • (2000) Proc AMIA Symp , pp. 27-31
    • Ash, J.S.1    Gorman, P.N.2    Lavelle, M.3
  • 18
    • 0035089308 scopus 로고    scopus 로고
    • Impact of an electronic information system on physician workflow and data collection in the intensive care unit
    • Apkon M, Singhaviranon P. Impact of an electronic information system on physician workflow and data collection in the intensive care unit. Intensive Care Med 2001;27:122-30.
    • (2001) Intensive Care Med , vol.27 , pp. 122-130
    • Apkon, M.1    Singhaviranon, P.2
  • 19
    • 0032944688 scopus 로고    scopus 로고
    • Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions
    • Tang PC, LaRosa MP, Gorden SM. Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. J Am Med Inform Assoc 1999;6:245-51.
    • (1999) J Am Med Inform Assoc , vol.6 , pp. 245-251
    • Tang, P.C.1    LaRosa, M.P.2    Gorden, S.M.3
  • 20
    • 0038772388 scopus 로고    scopus 로고
    • The electronic patient record in primary care-regression or progression? A cross sectional study
    • Hippisley-Cox J, Pringle M, Cater R, et al. The electronic patient record in primary care-regression or progression? A cross sectional study. BMJ 2003;326:1439-43.
    • (2003) BMJ , vol.326 , pp. 1439-1443
    • Hippisley-Cox, J.1    Pringle, M.2    Cater, R.3
  • 21
    • 57649107234 scopus 로고    scopus 로고
    • Electronic health record components and the quality of care
    • Keyhani S, Hebert PL, Ross JS, et al. Electronic health record components and the quality of care. Med Care 2008;46:1267-72.
    • (2008) Med Care , vol.46 , pp. 1267-1272
    • Keyhani, S.1    Hebert, P.L.2    Ross, J.S.3
  • 22
    • 0035180346 scopus 로고    scopus 로고
    • The use of electronic medical records: communication patterns in outpatient encounters
    • Makoul G, Curry RH, Tang PC. The use of electronic medical records: communication patterns in outpatient encounters. J Am Med Inform Assoc 2001;8:610-15.
    • (2001) J Am Med Inform Assoc , vol.8 , pp. 610-615
    • Makoul, G.1    Curry, R.H.2    Tang, P.C.3
  • 23
    • 3042750011 scopus 로고    scopus 로고
    • Are electronic medical records trustworthy? Observations on copying, pasting and duplication
    • Hammond KW, Helbig ST, Benson CC, et al. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. Proc AMIA Symp 2003:269-73.
    • (2003) Proc AMIA Symp , pp. 269-273
    • Hammond, K.W.1    Helbig, S.T.2    Benson, C.C.3
  • 24
    • 0037234321 scopus 로고    scopus 로고
    • Direct text entry in electronic progress notes-an evaluation of input errors
    • Weir C, Hurdle J, Felgar M, et al. Direct text entry in electronic progress notes-an evaluation of input errors. Methods Inf Med 2003;42:1-110.
    • (2003) Methods Inf Med , vol.42 , pp. 1-110
    • Weir, C.1    Hurdle, J.2    Felgar, M.3
  • 25
    • 45849109216 scopus 로고    scopus 로고
    • Preliminary development of the physician documentation quality instrument
    • Stetson PD, Morrison FP, Bakken S, et al. Preliminary development of the physician documentation quality instrument. J Am Med Inform Assoc 2008;15:534-41.
    • (2008) J Am Med Inform Assoc , vol.15 , pp. 534-541
    • Stetson, P.D.1    Morrison, F.P.2    Bakken, S.3
  • 26
    • 79953093873 scopus 로고    scopus 로고
    • Data from clinical notes: a perspective on the tension between structure and flexible documentation
    • Rosenbloom ST, Denny JC, Xu H, et al. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011;18:181-6.
    • (2011) J Am Med Inform Assoc , vol.18 , pp. 181-186
    • Rosenbloom, S.T.1    Denny, J.C.2    Xu, H.3
  • 27
    • 33847640918 scopus 로고    scopus 로고
    • Cognitive factors influencing perceptions of clinical documentation tools
    • Rosenbloom ST, Crow AN, Blackford JU, et al. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform 2007;40:106-13.
    • (2007) J Biomed Inform , vol.40 , pp. 106-113
    • Rosenbloom, S.T.1    Crow, A.N.2    Blackford, J.U.3
  • 28
    • 0032192460 scopus 로고    scopus 로고
    • Considerations for sociotechnical design: experiences with an electronic patient record in a clinical context
    • Berg M, Langenberg C, vd Berg I, et al. Considerations for sociotechnical design: experiences with an electronic patient record in a clinical context. Int J Med Inform 1998;52:243-51.
    • (1998) Int J Med Inform , vol.52 , pp. 243-251
    • Berg, M.1    Langenberg, C.2    Vd Berg, I.3
  • 29
    • 0026394440 scopus 로고
    • Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508)
    • United States Congress
    • United States Congress. Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508). Health Care Financ Rev 1991;13:115-34.
    • (1991) Health Care Financ Rev , vol.13 , pp. 115-134
  • 30
    • 0035871294 scopus 로고    scopus 로고
    • Computerized medical records in the Department of Veterans Affairs
    • Fletcher RD, Dayhoff RE, Wu CM, et al. Computerized medical records in the Department of Veterans Affairs. Cancer 2001;91(8 Suppl.):1603-6.
    • (2001) Cancer , vol.91 , Issue.8 SUPPL. , pp. 1603-1606
    • Fletcher, R.D.1    Dayhoff, R.E.2    Wu, C.M.3
  • 33
    • 0025228844 scopus 로고
    • Knowledge resource preferences of family physicians
    • Connelly DP, Rich EC, Curley SP, et al. Knowledge resource preferences of family physicians. J Fam Pract 1990;30:353-9.
    • (1990) J Fam Pract , vol.30 , pp. 353-359
    • Connelly, D.P.1    Rich, E.C.2    Curley, S.P.3
  • 35
    • 58149157912 scopus 로고    scopus 로고
    • Physicians' attitudes towards copy and pasting in electronic note writing
    • O'Donnell HC, Kaushal R, Barron Y, et al. Physicians' attitudes towards copy and pasting in electronic note writing. J Gen Intern Med 2009;24:63-8.
    • (2009) J Gen Intern Med , vol.24 , pp. 63-68
    • O'Donnell, H.C.1    Kaushal, R.2    Barron, Y.3
  • 36
    • 34247197212 scopus 로고    scopus 로고
    • Copying and pasting of examinations within the electronic medical record
    • Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform 2007;76(Suppl. 1):S122-8.
    • (2007) Int J Med Inform , vol.76 , Issue.SUPPL. 1
    • Thielke, S.1    Hammond, K.2    Helbig, S.3
  • 37
    • 33750980663 scopus 로고    scopus 로고
    • Copy-and-paste-and-paste
    • author reply 15-16
    • Yackel TR, Embi PJ. Copy-and-paste-and-paste. JAMA 2006;296:2315; author reply 15-16.
    • (2006) JAMA , vol.296 , pp. 2315
    • Yackel, T.R.1    Embi, P.J.2
  • 38
    • 79960559057 scopus 로고    scopus 로고
    • Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review
    • Collins SA, Stein DM, Vawdrey DK, et al. Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review. J Biomed Inform 2011;44:704-12.
    • (2011) J Biomed Inform , vol.44 , pp. 704-712
    • Collins, S.A.1    Stein, D.M.2    Vawdrey, D.K.3
  • 39
    • 79960042563 scopus 로고    scopus 로고
    • An exploration of the impact of computerized patient documentation on clinical collaboration
    • Weir CR, Hammond KW, Embi PJ, et al. An exploration of the impact of computerized patient documentation on clinical collaboration. Int J Med Inform 2011;80:e62-71.
    • (2011) Int J Med Inform , vol.80
    • Weir, C.R.1    Hammond, K.W.2    Embi, P.J.3
  • 41
    • 84964922694 scopus 로고    scopus 로고
    • Initial steps toward validating and measuring the quality of computerized provider documentation
    • Hammond KW, Efthimiadis EN, Weir CR, et al. Initial steps toward validating and measuring the quality of computerized provider documentation. AMIA Annu Symp Proc 2010;2010:271-5.
    • (2010) AMIA Annu Symp Proc , vol.2010 , pp. 271-275
    • Hammond, K.W.1    Efthimiadis, E.N.2    Weir, C.R.3
  • 42
    • 33845436726 scopus 로고    scopus 로고
    • A cognitive task analysis of information management strategies in a computerized provider order entry environment
    • Weir CR, Nebeker JJ, Hicken BL, et al. A cognitive task analysis of information management strategies in a computerized provider order entry environment. J Am Med Inform Assoc 2007;14:65-75.
    • (2007) J Am Med Inform Assoc , vol.14 , pp. 65-75
    • Weir, C.R.1    Nebeker, J.J.2    Hicken, B.L.3
  • 43
    • 69749119820 scopus 로고    scopus 로고
    • Toward reuse of clinical data for research and quality improvement: the end of the beginning?
    • Weiner MG, Embi PJ. Toward reuse of clinical data for research and quality improvement: the end of the beginning? Ann Intern Med 2009;151:359-60.
    • (2009) Ann Intern Med , vol.151 , pp. 359-60
    • Weiner, M.G.1    Embi, P.J.2
  • 44
    • 73449122615 scopus 로고    scopus 로고
    • Biomedical informatics and outcomes research: enabling knowledge-driven health care
    • Embi PJ, Kaufman SE, Payne PR. Biomedical informatics and outcomes research: enabling knowledge-driven health care. Circulation 2009;120:2393-9.
    • (2009) Circulation , vol.120 , pp. 2393-29
    • Embi, P.J.1    Kaufman, S.E.2    Payne, P.R.3
  • 45
    • 72949114284 scopus 로고    scopus 로고
    • Translational informatics: enabling high-throughput research paradigms
    • Payne PR, Embi PJ, Sen CK. Translational informatics: enabling high-throughput research paradigms. Physiol Genomics 2009;39:131-40.
    • (2009) Physiol Genomics , vol.39 , pp. 131-140
    • Payne, P.R.1    Embi, P.J.2    Sen, C.K.3
  • 46
    • 77957694296 scopus 로고    scopus 로고
    • Faculty, resident, and clinic staff's evaluation of the effects of EHR implementation
    • Bloom MV, Huntington MK. Faculty, resident, and clinic staff's evaluation of the effects of EHR implementation. Fam Med 2010;42:562-6.
    • (2010) Fam Med , vol.42 , pp. 562-566
    • Bloom, M.V.1    Huntington, M.K.2
  • 47
    • 79958295175 scopus 로고    scopus 로고
    • Alternative measures of electronic health record adoption among hospitals
    • Blavin FE, Buntin MJ, Friedman CP. Alternative measures of electronic health record adoption among hospitals. Am J Manag Care 2010;16(12 Suppl. HIT): e293-301.
    • (2010) Am J Manag Care , vol.16 , Issue.12 SUPPL. HIT
    • Blavin, F.E.1    Buntin, M.J.2    Friedman, C.P.3
  • 48
    • 79960065265 scopus 로고    scopus 로고
    • Model development for EHR interdisciplinary information exchange of ICU common goals
    • Collins SA, Bakken S, Vawdrey DK, et al. Model development for EHR interdisciplinary information exchange of ICU common goals. Int J Med Inform 2011;80:e141-9.
    • (2011) Int J Med Inform , vol.80
    • Collins, S.A.1    Bakken, S.2    Vawdrey, D.K.3
  • 49
    • 79952018498 scopus 로고    scopus 로고
    • Lessons learned from implementation of voice recognition for documentation in the military electronic health record system
    • Hoyt R, Yoshihashi A. Lessons learned from implementation of voice recognition for documentation in the military electronic health record system. Perspectives in Health Information Management/AHIMA 2010;7:1e.
    • (2010) Perspectives in Health Information Management/AHIMA , vol.7
    • Hoyt, R.1    Yoshihashi, A.2
  • 50
    • 73449142545 scopus 로고    scopus 로고
    • Communication and documentation considerations for electronic health records
    • Gaffey AD. Communication and documentation considerations for electronic health records. J Healthc Risk Manag 2009;29:16-20.
    • (2009) J Healthc Risk Manag , vol.29 , pp. 16-20
    • Gaffey, A.D.1
  • 51
    • 41149088350 scopus 로고    scopus 로고
    • Definition, structure, content, use and impacts of electronic health records: a review of the research literature
    • Hayrinen K, Saranto K, Nykanen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int J Med Inform 2008;77:291-304.
    • (2008) Int J Med Inform , vol.77 , pp. 291-304
    • Hayrinen, K.1    Saranto, K.2    Nykanen, P.3
  • 52
    • 84892674797 scopus 로고    scopus 로고
    • The future state of clinical data capture and documentation: a report from AMIA's 2011 Policy Meeting
    • Cusack CM, Hripcsak G, Bloomrosen M, et al. The future state of clinical data capture and documentation: a report from AMIA's 2011 Policy Meeting. J Am Med Inform Assoc 2012;77:291-304.
    • (2012) J Am Med Inform Assoc , vol.77 , pp. 291-304
    • Cusack, C.M.1    Hripcsak, G.2    Bloomrosen, M.3


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.