title: Physician-Driven Management of Patient Progress Notes in an Intensive Care Unit.
abstract: We describe fieldwork in which we studied hospital ICU physicians and their strategies and documentation aids for composing patient progress notes. We then present a clinical documentation prototype, activeNotes, that supports the creation of these notes, using techniques designed based on our fieldwork. ActiveNotes integrates automated, context-sensitive patient data retrieval, and user control of automated data updates and alerts via tagging, into the documentation process. We performed a qualitative study of activeNotes with 15 physicians at the hospital to explore the utility of our information retrieval and tagging techniques. The physicians indicated their desire to use tags for a number of purposes, some of them extensions to what we intended, and others new to us and unexplored in other systems of which we are aware. We discuss the physicians' responses to our prototype and distill several of their proposed uses of tags: to assist in note content management, communication with other clinicians, and care delivery.
authors.affiliation: IBM Watson Research Center, 19 Skyline Drive ; Department of Computer Science, Columbia University.
authors.forename: Lauren
authors.initials: L
authors.lastname: Wilcox
authors.affiliation: IBM Watson Research Center, 19 Skyline Drive.
authors.forename: Jie
authors.initials: J
authors.lastname: Lu
authors.affiliation: IBM Watson Research Center, 19 Skyline Drive.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Lai
authors.affiliation: Department of Computer Science, Columbia University.
authors.forename: Steven
authors.initials: S
authors.lastname: Feiner
authors.affiliation: College of Physicians and Surgeons, Columbia University.
authors.forename: Desmond
authors.initials: D
authors.lastname: Jordan
keywords: H5.2 [Information Interfaces]: User Interfaces, Input; I.3.6 [Methodology and techniques]: Interaction Techniques; Medical note creation; clinical documentation; clinical notes; medical user interfaces; tags