Browsing by Subject "Documentation"

Now showing 1 - 6 of 6
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    Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs
    (Springer Nature, 2024-07-18) Weiner, Michael; Flanagan, Mindy E.; Ernst, Katie; Cottingham, Ann H.; Rattray, Nicholas A.; Franks, Zamal; Savoy, April W.; Lee, Joy L.; Frankel, Richard M.; Medicine, School of Medicine
    Background: Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality. Methods: Patients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality. Results: Encounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points. Conclusions: Among outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.
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    Assessing the relationship between medical residents’ perceived barriers to SBIRT implementation and their documentation of SBIRT in clinical practice
    (Elsevier, 2014-08) Agley, J.; Gassman, R. A.; Vannerson, J.; Crabb, D.; Department of Medicine, Division of General Internal Medicine, IU School of Medicine
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    Do electronic health record systems "dumb down" clinicians?
    (Oxford University Press, 2022) Melton, Genevieve B.; Cimino, James J.; Lehmann, Christoph U.; Sengstack, Patricia R.; Smith, Joshua C.; Tierney, William M.; Miller, Randolph A.; Community and Global Health, Richard M. Fairbanks School of Public Health
    A panel sponsored by the American College of Medical Informatics (ACMI) at the 2021 AMIA Symposium addressed the provocative question: "Are Electronic Health Records dumbing down clinicians?" After reviewing electronic health record (EHR) development and evolution, the panel discussed how EHR use can impair care delivery. Both suboptimal functionality during EHR use and longer-term effects outside of EHR use can reduce clinicians' efficiencies, reasoning abilities, and knowledge. Panel members explored potential solutions to problems discussed. Progress will require significant engagement from clinician-users, educators, health systems, commercial vendors, regulators, and policy makers. Future EHR systems must become more user-focused and scalable and enable providers to work smarter to deliver improved care.
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    Forced Inefficiencies of the Electronic Health Record
    (Springer, 2019-11) Weiner, Michael; Regenstrief Institute, IU School of Medicine
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    Hands-Free Electronic Documentation in Emergency Care Work Through Smart Glasses
    (Springer, 2022-02) Zhang, Zhan; Luo, Xiao; Harris, Richard; George, Susanna; Finkelstein, Jack; Computer Information and Graphics Technology, School of Engineering and Technology
    As U.S. healthcare system moves towards digitization, Electronic Health Records (EHRs) are increasingly adopted by medical providers. However, EHR documentation is not only time-consuming but also difficult to complete in real-time, leading to delayed, missing, or erroneous data entry. This challenge is more evident in time-critical and hands-busy clinical domains, such as Emergency Medical Services (EMS). In recent years, smart glasses have gained momentum in supporting various aspects of clinical care. However, limited research has examined the potential of smart glasses in automating electronic documentation during fast-paced medical work. In this paper, we report the design, development, and preliminary evaluations of a novel system combining smart glasses and EHRs and leveraging natural language processing (NLP) techniques to enable hands-free, real-time documentation in the context of EMS care. Although optimization is needed, our system prototype represents a substantive departure from the status quo in the documentation technology for emergency care providers, and has a high potential to enable real-time documentation while accounting for care providers’ cognitive and physical constraints imposed by the time-critical medical environment.
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    Impact of Community Health Workers on Elderly Patients' Advance Care Planning and Health Care Utilization: Moving the Dial
    (Lippincott, Williams & Wilkins, 2017-04) Litzelman, Debra K.; Inui, Thomas S.; Griffin, Wilma J.; Perkins, Anthony; Cottingham, Ann H.; Wendholt, Kathleen M.; Ivy, Steven S.; Medicine, School of Medicine
    BACKGROUND: Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. OBJECTIVE: To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. RESEARCH DESIGN: A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation. SUBJECTS: The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white. MEASURES: Documentation of ACP conversation in electronic health record fields and health care utilization outcomes. RESULTS: In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45-0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. CONCLUSIONS: Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.