Literature DB >> 15325323

Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey.

Kevin B Johnson1, William J Ravich, John A Cowan.   

Abstract

UNLABELLED: Computer-based software to record histories, physical exams, and progress or procedure notes, known as computer-based documentation (CBD) software, has been touted as an important addition to the electronic health record. The functionality of CBD systems has remained static over the past 30 years, which may have contributed to the limited adoption of these tools. Early users of this technology, who have tried multiple products, may have insight into important features to be considered in next-generation CBD systems. OBJECTIVE AND METHODS: We conducted a cross-sectional, observational study of the clinical working group membership of the American Medical Informatics Association (AMIA) to generate a set of features that might improve adoption of next-generation systems. The study was conducted online over a 4-month period; 57% of the working group members completed the survey.
RESULTS: As anticipated, CBD tool use was higher (53%) in this population than in the US physician offices. The most common methods of data entry employed keyboard and mouse, with agreement that these modalities worked well. Many respondents had experience with pre-printed data collection forms before interacting with a CBD system. Respondents noted that CBD improved their ability to document large amounts of information, allowed timely sharing of information, enhanced patient care, and enhanced medical information with other clinicians (all P < 0.001). Respondents also noted some important but absent features in CBD, including the ability to add images, get help, and generate billing information.
CONCLUSIONS: The latest generation of CBD systems is being used successfully by early adopters, who find that these tools confer many advantages over the approaches to documentation that they replaced. These users provide insights that may improve successive generations of CBD tools. Additional surveys of CBD non-users and failed adopters will be necessary to provide other useful insights that can address barriers to the adoption of CBD by less computer literate physicians.

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Year:  2004        PMID: 15325323     DOI: 10.1016/j.ijmedinf.2004.05.009

Source DB:  PubMed          Journal:  Int J Med Inform        ISSN: 1386-5056            Impact factor:   4.046


  13 in total

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4.  Direct comparison of MEDCIN and SNOMED CT for representation of a general medical evaluation template.

Authors:  Steven H Brown; S Trent Rosenbloom; Brent A Bauer; Dietlind Wahner-Roedler; David A Froehling; Kent R Bailey; Michael J Lincoln; Diane Montella; Elliot M Fielstein; Peter L Elkin
Journal:  AMIA Annu Symp Proc       Date:  2007-10-11

5.  Using EHR audit trail logs to analyze clinical workflow: A case study from community-based ambulatory clinics.

Authors:  Danny T Y Wu; Nikolas Smart; Elizabeth L Ciemins; Holly J Lanham; Curt Lindberg; Kai Zheng
Journal:  AMIA Annu Symp Proc       Date:  2018-04-16

6.  Quantifying clinical data quality using relative gold standards.

Authors:  Michael G Kahn; Brian B Eliason; Janet Bathurst
Journal:  AMIA Annu Symp Proc       Date:  2010-11-13

7.  Data from clinical notes: a perspective on the tension between structure and flexible documentation.

Authors:  S Trent Rosenbloom; Joshua C Denny; Hua Xu; Nancy Lorenzi; William W Stead; Kevin B Johnson
Journal:  J Am Med Inform Assoc       Date:  2011-01-12       Impact factor: 4.497

8.  A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians.

Authors:  Rubina F Rizvi; Kathleen A Harder; Gretchen M Hultman; Terrence J Adam; Michael Kim; Serguei V S Pakhomov; Genevieve B Melton
Journal:  Int J Med Inform       Date:  2016-03-02       Impact factor: 4.046

9.  A qualitative analysis evaluating the purposes and practices of clinical documentation.

Authors:  Y-X Ho; C S Gadd; K L Kohorst; S T Rosenbloom
Journal:  Appl Clin Inform       Date:  2014-02-26       Impact factor: 2.342

Review 10.  Possibilities and Implications of Using the ICF and Other Vocabulary Standards in Electronic Health Records.

Authors:  Daniel J Vreeman; Christophe Richoz
Journal:  Physiother Res Int       Date:  2013-07-30
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