A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians.
OBJECTIVE
The objective of this study is to understand physicians' usage of inpatient notes by (i) ascertaining different clinical note-entry and reading/retrieval styles in two different and widely used Electronic Health Record (EHR) systems, (ii) extrapolating potential factors leading to adoption of various note-entry and reading/retrieval styles and (iii) determining the amount of time to task associated with documenting different types of clinical notes.


METHODS
In order to answer "what" and "why" questions on physicians' adoption of certain-note-entry and reading/retrieval styles, an ethnographic study entailing Internal Medicine residents, with a mixed data analysis approach was performed. Participants were observed interacting with two different EHR systems in inpatient settings. Data was collected around the use and creation of History and Physical (H&P) notes, progress notes and discharge summaries.


RESULTS
The highest variability in template styles was observed with progress notes and the least variability was within discharge summaries, while note-writing styles were most consistent for H&P notes. The first sections to be read in a H&P and progress note were the Chief Complaint and Assessment & Plan sections, respectively. The greatest note retrieval variability, with respect to the order of how note sections were reviewed, was observed with H&P and progress notes. Physician preference for adopting a certain reading/retrieval order appeared to be a function of what best fits their workflow while fulfilling the stimulus demands. The time spent entering H&P, discharge summaries and progress notes were similar in both EHRs.


CONCLUSIONS
This research study unveils existing variability in clinical documentation processes and provides us with important information that could help in designing a next generation EHR Graphical User Interface (GUI) that is more congruent with physicians' mental models, task performance needs, and workflow requirements.
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States.
Rubina F
RF
Rizvi
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; Center for Design in Health, College of Design, University of Minnesota, Minneapolis, MN, United States.
Kathleen A
KA
Harder
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States.
Gretchen M
GM
Hultman
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; College of Pharmacy, University of Minnesota, Minneapolis, MN, United States.
Terrence J
TJ
Adam
Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States.
Michael
M
Kim
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; College of Pharmacy, University of Minnesota, Minneapolis, MN, United States.
Serguei V S
SV
Pakhomov
Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States; Department of Surgery, University of Minnesota, Minneapolis, MN, United States. Electronic address: gmelton@umn.edu.
Genevieve B
GB
Melton
D000328:Adult; D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D007297:Inpatients; D007388:Internal Medicine / Q000379:methods*; D008297:Male; D010347:Patient Care Planning; D010820:Physicians / Q000523:psychology*; D010818:Practice Patterns, Physicians'; D011932:Reading; D014584:User-Computer Interface; D014956:Writing
Clinical documentation; Electronic health records systems (EHR); Graphical User Interface (GUI); Human-Computer Interaction (HCI); Qualitative analysis; Usability