Managing the life cycle of electronic clinical documents.
OBJECTIVE
To develop a model of the life cycle of clinical documents from inception to use in a person's medical record, including workflow requirements from clinical practice, local policy, and regulation.


METHODS
We propose a model for the life cycle of clinical documents as a framework for research on documentation within electronic medical record (EMR) systems. Our proposed model includes three axes: the stages of the document, the roles of those involved with the document, and the actions those involved may take on the document at each stage. The model includes the rules to describe who (in what role) can perform what actions on the document, and at what stages they can perform them. Rules are derived from needs of clinicians, and requirements of hospital bylaws and regulators.


RESULTS
Our model encompasses current practices for paper medical records and workflow in some EMR systems. Commercial EMR systems include methods for implementing document workflow rules. Workflow rules that are part of this model mirror functionality in the Department of Veterans Affairs (VA) EMR system where the Authorization/ Subscription Utility permits document life cycle rules to be written in English-like fashion.


CONCLUSIONS
Creating a model of the life cycle of clinical documents serves as a framework for discussion of document workflow, how rules governing workflow can be implemented in EMR systems, and future research of electronic documentation.
Payne
Thomas H
TH
UW Medicine Information Technology Services, University of Washington, 9725 3rd Avenue N.E. Room 513, Box 359104, Seattle, Washington 98115-2024, USA. tpayne@u.washington.edu
Graham
Gail
G
D004282:Documentation; D005568:Forms and Records Control / Q000458:organization & administration*; D006753:Hospital Records; D006801:Humans; D008499:Medical Records; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D014481:United States; D014493:United States Department of Veterans Affairs