Efficiency Strategies for Facilitating Computerized Clinical Documentation in Ambulatory Care

1. Efficiency Strategies for Facilitating Computerized Clinical Documentation in Ambulatory Care Jason J. Saleem, PhD US Department of Veterans Affairs Regenstrief Institute, Inc. 22 August 2013

2. Background • Clinical documentation is a core activity for healthcare professionals and accounts for a substantial portion of a clinician’s workday. • Documentation demands increase with the use of an electronic health record (EHR). • Much research has been done regarding the specific content and quality of provider notes. • Little research exists on how providers’ documentation activities fit into their workflow and support their cognitive needs. • Study Aim: Identify strategies providers have developed to keep up with clinical documentation demands. • Framework: Distributed cognition

3. Computerized Patient Record System (CPRS) *Fictitious patient record*

4. Methods • Study site: US Veterans Affairs Medical Center (VAMC) • Sample: 22 ambulatory care providers • Primary care, cardiology, dialysis, nutrition, orthopedics, renal, and the polytrauma unit • “Rapid” ethnographic observation (n=18) • 10 physicians, 3 nurse practitioners, 2 clinical pharmacists, 1 physician assistant, 1 clinical psychologist, and 1 registered dietician. • Semi-structured, key-informant interviews (n=4) • Selection was based on their unique positions or knowledge about clinical documentation

5. Analysis of qualitative data (observation notes, interview transcripts) Figure adapted from: Roth, EM., Patterson, ES. Using observational study as a tool for discovery: uncovering cognitive demands and adaptive strategies, in: H. Montgomery, R. Lipshitz, B. Brehmer (Eds.), How Professionals Make Decisions, Lawrence Erlbaum Associates, Inc., Mahwah, New Jersey, 2005, pp. 379–393.

6. Results

7. Results (continued)

8. Results (continued)

9. Distributed cognition Before patient encounter During patient encounter After patient encounter Patient Paper artifact Paper artifact Paper artifact d b c f g a e EHR EHR EHR Provider Provider Provider

10. Barriers to documentation • Higher priorities, workload, and time pressure • “My priority is to take care of the patient – at the expense of documentation...” • Electronic template design

11. Workload management strategies • Rescheduling tasks • Deferring or shedding tasks • Reducing performance criteria • Recruiting additional resources to complete tasks

12. Conclusion • Strategies to keep up with documentation demands • Paper artifacts are often helpful and should be coordinated with the EHR to avoid gaps in documentation. • Make it easier for providers to directly enter notes into the EHR, in a way that fits their preferred workflow and minimizes negative impact on their interaction with the patient. • Uninterrupted note composition is the model for many current EHRs. • Next-generation EHRs can better facilitate clinical documentation by supporting information synthesis and sense-making.

13. Acknowledgements • US Department of Veterans Affairs • Health Services Research and Development Service (HSR&D) Career Development Award (CDA 09-024-1) • Regenstrief Institute, Inc. • Co-authors: • Stephanie Adams, MFA • Richard Frankel, PhD • Brad Doebbeling, MD • Emily S. Patterson, PhD • Contact: Jason J. Saleem, PhD (Jason.Saleem@va.gov)