Clinician’s Computerized Documentation Adds More Problems
If you go along with my definition of medical records, computerized clinical narratives would constitute the major part of electronic medical records (EMR). EMR offers many benefits as better accessibility and increased legibility. However, concerning patterns emerged when full computerization of medical documents was carried out. I will present Weir and Nebeker (2007) qualitative study done to assess Veterans Affairs EMR computerized clinicians’ narratives. The studied system offered clinicians with multiple methods to enter data:
- dictation (only 1% of documents were dictated)
- manual entry facilitated by:
- templates
- objects. objects are parts of documentation that could be used multiple times as patient identification, medication lists and problem lists.
- copy and paste
Negative effect on work process was one of the emerging themes. This is usually noticed with any sort of computerization. However, much more concerning themes, that can undermine the purpose of clinician documentation appeared. These themes are:
- Increase documents length; with redundancy, poor formatting and overall increased clutter. This undermines the goal of efficient transfer of information.
- Concerns over mistakes. Text entry facilitation as by copying and pasting and by using templates caused wrong data to be entered. Clinicians were missing data needed modification from their original source before being used.
Weir and Nebeker conclude that studied computerized documents violated four normative expectations of documentation:
- succinctness and precision
- correct portrayal of decision process
- temporal accuracy
- consistent format
These findings are not unique to studied system. Weir and Nebeker (2007) preset thee other studies that had similar concerns.
Computerization of medical records should not induce documentation mistakes. I have two possible solutions the can realistically limit these drawbacks of computerized documents:
1. Do not target the computerization of all documents. The problems noticed were with notes daily taken by clinicians as progress notes. But, continue to computerized documents that will usually be needed across longer time as discharge summaries.
2. If the decision is to go ahead with computerization of all medical documents, then a fairly detailed impression/assessment should be typed by the clinician at the end of their notes. The use of facilitated text entry methods as copying and pasting should not be used. This impression/assessment should be one to three sentences in length (per problem).
Weir, C.R. & Nebeker, J.R., 2007. Critical Issues in an Electronic Documentation System. AMIA Annual Symposium Proceedings, 2007, 786–790.
It seems to me that you argue against the worth of CDS in a busy ocffie practice. Actually you made the case at Relevance . The other points were just window dressing. For CDS to work effectively in a busy clinical practice, one would need vary fast (expensive) processors with ability to frequently upgrade equipment. The only piece that seems useful (drug interaction check) usually becomes very slow in patients with poly-pharmacy (10-15 drugs). These are the patients that we really need to run these checks, but a lot of time elapse while a system cross-checks 15 drugs. The answer to your question, unfortunately is no . CDS can perhaps help one avoid major mistakes, if used appropriately, but that does not define a good clinician.
Thank you for your comment.
I am against over automation. There are parts of Electronic Heath Records that lend themselves to full automation, as drug checks (your example). However, other parts as clinicians narratives ( as progress notes) do not lend themselves to automation. In the quoted study automating this part produces unwanted effects.