Efficiency strategies for facilitating computerized clinical documentation in ambulatory care

Studies in Health Technology and Informatics

Volumn 192, Issue 1-2, 2013, Pages 13-17

  Saleem, Jason J ^a,b,c   Adams, Stephanie ^a   Frankel, Richard M ^a,b,c   Doebbeling, Bradley N ^a,b,c   Patterson, Emily S ^d  

^a VA HSR and D Center on Implementing Evidence based Practice   (United States)

^b REGENSTRIEF INSTITUTE   (United States)

^c INDIANA UNIVERSITY   (United States)

^d THE OHIO STATE UNIVERSITY COLLEGE OF MEDICINE   (United States)

Author keywords

Clinical documentation; Electronic health records; Human factors; Workflow; Workload

Indexed keywords

EFFICIENCY; HUMAN COMPUTER INTERACTION; HUMAN ENGINEERING; RECORDS MANAGEMENT;

CLINICAL DOCUMENTATION; CLINICAL INFORMATION; DISTRIBUTED COGNITION; ELECTRONIC HEALTH RECORD; ELECTRONIC HEALTH RECORD (EHRS); ETHNOGRAPHIC OBSERVATIONS; WORKFLOW; WORKLOAD;

HEALTH;

ADULT; AMBULATORY CARE; DOCUMENTATION; ELECTRONIC MEDICAL RECORD; FEMALE; HUMAN; INFORMATION RETRIEVAL; MALE; MIDDLE AGED; PROCEDURES; STATISTICS AND NUMERICAL DATA; WORKLOAD; WRITING;

ADULT; AMBULATORY CARE; DOCUMENTATION; ELECTRONIC HEALTH RECORDS; FEMALE; HUMANS; INFORMATION STORAGE AND RETRIEVAL; MALE; MIDDLE AGED; WORKLOAD; WRITING;

EID: 84894295854     PISSN: 09269630     EISSN: 18798365     Source Type: Book Series    
DOI: 10.3233/978-1-61499-289-9-13     Document Type: Conference Paper

References (32)

1. Gottschalk A, Flocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med 2005;3:488-93.
2. Hollingsworth JC, Chisholm CD, Giles BK, Cordell WH, Nelson DR. How do physicians and nurses spend their time in the emergency department? Ann Emerg Med 1998;31:87-91.
3. Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic clinical documentation: time spent and team interactions. J Am Med Inform Assoc 2011;18:112-7.
4. Oxentenko AS, West CP, Popkave C, Weinberger SE, Kolars JC. Time spent on clinical documentation: a survey of internal medicine residents and program directors. Arch Intern Med 2010;170:377-80.
5. Ammenwerth E, Spotl HP. The time needed for clinical documentation versus direct patient care. A worksampling analysis of physicians' activities. Methods Inf Med 2009;48:84-91.
6. Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. Health Aff (Millwood ) 2004;23:116-26.
7. Pizziferri L, Kittler AF, Volk LA, Honour MM, Gupta S, Wang S, Wang T, Lippincott M, Li Q, Bates DW. Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study. J Biomed Inform 2005;38:176-88.
8. Powsner SM, Wyatt JC, Wright P. Opportunities for and challenges of computerisation. Lancet 1998;352:1617-22.
9. Mamykina L, Vawdrey DK, Stetson PD, Zheng K, Hripcsak G. Clinical documentation: composition or synthesis? J Am Med Inform Assoc 2012;19:1025-31.
10. Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med 2010;362:1066-9.
11. Hammond KW, Helbig ST, Benson CC, Brathwaite-Sketoe BM. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc 2003:269-73.
12. Mahler C, Ammenwerth E, Wagner A, Tautz A, Happek T, Hoppe B, Eichstadter R. Effects of a computer-based nursing documentation system on the quality of nursing documentation. J Med Syst 2007;31:274-82.
13. Payne TH, Patel R, Beahan S, Zehner J. The physical attractiveness of electronic physician notes. AMIA Annu Symp Proc 2010;2010:622-6.
14. Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med 2003;42:61-7.
15. Cusack CM, Hripcsak G, Bloomrosen M, Rosenbloom ST, Weaver CA, Wright A, Vawdrey DK, Walker J, Mamykina L. The future state of clinical data capture and documentation: a report from AMIA's 2011 Policy Meeting. J Am Med Inform Assoc 2012;20:134-40.
16. Hutchins E. Cognition in the Wild. Cambridge, MA: MIT Press; 1995.
17. Saleem JJ, Russ AL, Sanderson P, Johnson TR, Zhang J, Sittig DF. Current challenges and opportunities for better integration of human factors research with development of clinical information systems. Yearb Med Inform 2009:48-58.
18. Hutchins E. How a cockpit remembers its speed. Cognitive Science 1995;19:265-88.
19. Cohen T, Blatter B, Almeida C, Shortliffe E, Patel VL. A cognitive blueprint of collaboration in context: distributed cognition in the psychiatric emergency department. Artificial Intelligence in Medicine 2006;37:73-83.
20. Hazlehurst B, Gorman PN, McMullen CK. Distributed cognition: an alternative model of cognition for medical informatics. Int J Med Inform 2008;77:226-34.
21. Patel VL, Zhang J, Yoskowitz NA, Green R, Sayan OR. Translational cognition for decision support in critical care environments: a review. J Biomed Inform 2008;41:413-31.
22. Patel VL, Cytryn KN, Shortliffe EH, Safran C. The collaborative health care team: the role of individual and group expertise. Teach Learn Med 2000;12:117-32.
23. Nardi BA. Studying context: a comparison of activity theory, situated action models, and distributed cognition. In: Nardi BA, editor. Context and Consciousness: Activity Theory and Human-Computer Interaction. Cambridge, MA: MIT Press; 1996. p 69-102.
24. Wright PC, Fields RE, Harrison MD. Analyzing humancomputer interaction as distributed cognition: the resources model. Human-Computer Interaction 2000;15:1-41.
25. Saleem JJ, Patterson ES, Militello L, Render ML, Orshansky G, Asch SM. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc 2005;12:438-47.
26. McMullen CK, Ash JS, Sittig DF, Bunce A, Guappone K, Dykstra R, Carpenter J, Richardson J, Wright A. Rapid assessment of clinical information systems in the healthcare setting: an efficient method for time-pressed evaluation. Methods Inf Med 2011;50:299-307.
27. Brown SH, Lincoln MJ, Groen PJ, Kolodner RM. VistA-U.S. Department of Veterans Affairs national-scale HIS. Int J Med Inform 2003;69:135-56.
28. 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.
29. Xiao Y, Vicente KJ. A framework for epistemological analysis in empirical (laboratory and field) studies. Hum Factors 2000;42:87-101.
30. Saleem JJ, Russ AL, Justice CF, Hagg H, Ebright PR, Woodbridge PA, Doebbeling BN. Exploring the persistence of paper with the electronic health record. Int J Med Inform 2009;78:618-28.
31. Patterson ES, Ebright PR, Saleem JJ. Investigating stacking: How do registered nurses prioritize their activities in real-time? Int J Ind Ergon 2011;41:389-93.
32. Huey BM, Wickens CD. Workload Transition: Implications for Individual and Team Performance Washington, D.C.: National Academy Press; 1993.