[Inf 295] week 9 parul seth documenting transitional information in emr
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This document summarizes a study examining electronic medical record (EMR) based documentation in an emergency department. The study observed the documentation practices of 57 clinical staff over 120 hours through 4 main roles and 2 information systems. It found that while EMRs organized relevant medical record categories, they did not fully support the informal documentation practices that facilitate collaboration. Specifically, the study revealed a parallel practice of recording transitional information on informal artifacts that carry provisional information needed to facilitate EMR documentation. The goal was to examine EMR documentation activities and their impact on clinical workflow issues in the complex emergency department environment.
[Inf 295] week 9 parul seth documenting transitional information in emr
- 1. Documenting Transitional Information in EMR Yunan Chen Presenter: Parul Seth University of California, Irvine INF 295 Topics In Health Informatics November 27th, 2013 1
- 2. BACKGROUND 2
- 3. Paper Medical Records Vs. Electronic Medical Records (EMR) 3
- 4. Electronic Medical Records Healthcare IT Reform plan says, “the majority of US hospitals will soon switch to EMR systems”. EMR is an information system that creates, gathers, manages and stores digital versions of patients’ paper charts within one healthcare organization system. Essentially, a documentation tool that supports clinical documentation activities. Improved Work Efficiency Increased Patient Safety Unintended Consequences Inefficiency Better Accountability & Billing Increased Workload 4
- 5. Problems Studies show that the documentation workload has increased after using the EMR system. Continued use of old paper records or workarounds. Ruling out paper is tough! Paper supports micro mobility, it is “handlable, manipulable, portable, dismantable”, easily organized. “Working records”, “provisional information”, “scraps” are used to facilitate team collaboration Though relevant categories of medical records are defined in the healthcare IT systems, “the practices through which the document is written, read and used within consultation have been largely ignored.” It is important to study “the computerized clinical documentation in complex clinical environments, especially the issues of efficiency associated with the EMR usage.” 5
- 6. Study Goal “To examine EMR based documentation in an Emergency Department (ED), with an emphasis on computerized documentation activities in the complex flow of clinical processes. With a focus on clinical workflow issues associated with the computerized documentation activities.” 6
- 7. Why Emergency Department (ED)? Work Efficiency is a dominant concern Patients experience entire treatment process in a short stay ED workflow notoriously complex due to diverse disease type and high time-constraint “A great opportunity to study documentation from different users and to see how the EMR system does or does not support the actual clinical workflow.” 7
- 8. Parallel Documentation Practice: Transitional Artifacts This study will reveal a parallel documentation practice that records informal information facilitating the flow of clinical work. The informal documentation is considered as Transitional Artifacts that carry the information needed to facilitate EMR-based documentation. 8
- 10. Study & Participants Observational Study at the Emergency Department (ED) of a large regional hospital located in the west coast. 57 clinical staff members, including 1 consulting physician, 11 attending's, 6 residents, 28 registered nurses, and 5 ED technicians. + Admitting staff members, case managers, discharge case planners, as well as social workers, working on the floor. ”This study consisted of a field observation of the computerized clinical documentation in the ED.” 10
- 11. Emergency Department @ Field Site 4 major units: a pediatric ED, an urgent care unit, a trauma center, and the main ED. The main ED has 2 nursing stations and a MD station surrounded by 12 patient rooms. The field observation covered the clinical documentation process in patients’ waiting rooms, triages, nursing stations, MD stations, patient rooms and other public areas in the ED. Main ED Area Map in the EMR 11
- 12. ED Documentation @ Field Site EMR system went live in July 2008. Old paper record system not used. Computers all over on the ED floor. 3 Computer-on-wheels (COW) ED layout designed to allow timely access to EMR. Tracker System: Another information system to track patient’s flows and show where patients are on the ED floor. Only one single path for patient treatment observed to illustrate the use of transitional artifacts (many other paths are possible). Single path: A patient walks into ED and is later admitted for hospitalization. 12
- 13. Data and Data Collection •Examining overall activities related to the ED patient flow with an emphasis on the documentation-related activities, the signoff activities for ED doctors and nurses, the ED admitting and discharging processes, as well as the shift change meetings. Field •Both day and night shifts, approximately 50% observation during ED peak times Observation Data Extraction Analysis •Data related to the ED documentation extracted from notes. •Data was then sorted & listed by roles of the ED staff and the treatment process. •Notes were then analyzed using an open coding technique to identify recurring patterns of documentation behaviors adopted by the ED staff. •Findings were not drawn from one individual patient treatment flow, but based on a synthesis of the recurring behaviors demonstrated by multiple ED staff in the same work role and linked together according to the steps of a patient’s ED visit procedures. •The patterns revealed in the study were further verified with the ED staff to ensure their validities. Verification ” 120 hours of field observation were performed over a period of 8 weeks. Each observation 4-5 Hours, with brief notes jotted down, detailed notes transcribed later.” 13
- 15. ED Workflow 15 “The ED documentation handled by four main roles and two information systems following patients’ treatment process.”
- 17. References Chen, Y. Documenting transitional information in EMR. Proceedings of the 28th international conference on Human factors in computing systems, ACM (2010), 1787–1796. All images have been searched and downloaded from Google Images 17
Editor's Notes
- #6: Since the implementation of the EMR one year ago, many doctors complained that they had to spend 1-2 more hours on documentation-related activities each shift, which left them less time for actual patient care. At the beginning, these issues may have resulted from unfamiliarity with the new technology. However, the higher workload continued to exist till the time this study was carried out - one year after the EMR implementation.Though relevant categories of medical records are defined in the healthcare IT systems,“the practices through which the document is written, read and used within consultation have been largely ignored.”Studying the computerized clinical documentation in complex clinical environments, especially the issues of efficiency associated with the EMR usage.
- #8: A great opportunity to study documentation from different users and to see how the EMR system does or does not support the actual clinical workflow
- #11: The general observation was able to cover the entire 57 ED staff during work, either briefly in the public area or through close shadowing. The author also followed 6 entire patients’ treatment processes, shadowed 5 ED doctors, 4 triage nurses, 5 room nurses and 2 case managers in order to obtain in-depth understanding about ED work and system usage patterns. In total, more than 100 patient cases were observed, either entire ED visits or partial processes such as triage process, diagnosis or discharge process.
- #12: The observation of this study was conducted in the main ED so that the researcher could easily observe the documentation activities and information flow among the various users of the EMR.
- #13: The primary goal of emergency medicine is to quickly stabilize patients’ situations and discharge patients out of an ED. The turnaround time for ED visits ranges from a couple of hours to a whole day, depending on the severity of an individual case. ED documentation captures all the detailed encounters between patients and ED staff, from the moment patients enter waiting room until they leave ED.
- #14: To protect patients’ confidentiality, the researcher stayed outside the patient rooms during the observation. However, since the workstations are mounted at the corner of patient rooms facing outside, the author was able to observe various bedside documentation activities while the room curtains were closed.120 hours of field observation were performed over a period of 8 weeks. Each observation 4-5 Hours, with brief notes jotted down, detailed notes transcribed later.
- #16: The ED documentation is handled by four main roles and two information systems following patients’ treatment process.