title: Leveraging systems thinking to design patient-centered clinical documentation systems.
abstract: A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. The failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. This paper seeks to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. It also addresses how rethinking clinical documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication.
authors.affiliation: Department of Biomedical Informatics, Columbia University, New York, NY, USA. marion.ball@healthlinkinc.com
authors.forename: Adam S
authors.initials: AS
authors.lastname: Rothschild
authors.forename: Linda
authors.initials: L
authors.lastname: Dietrich
authors.forename: Marion J
authors.initials: MJ
authors.lastname: Ball
authors.forename: Heidi
authors.initials: H
authors.lastname: Wurtz
authors.forename: Holly
authors.initials: H
authors.lastname: Farish-Hunt
authors.forename: Nhora
authors.initials: N
authors.lastname: Cortes-Comerer
mesh_terms: D017598:Efficiency, Organizational; D016347:Medical Records Systems, Computerized; D008501:Medical Records, Problem-Oriented; D009741:Nursing Staff, Hospital; D018802:Patient-Centered Care; D014481:United States