Documenting Transitional Informationin EMR

Yunan Chen

Presenter: Parul SethUniversity of California, IrvineINF 295 Topics In Health InformaticsNovember 27th, 2013

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BACKGROUND

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Paper Medical Records Vs. Electronic Medical Records (EMR)

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Electronic Medical Records

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Healthcare IT Reform plansays, “the majority of UShospitals will soon switch toEMR systems”.

EMR is an information system thatcreates, gathers, manages and stores digitalversions of patients’ paper charts within onehealthcare organization system. Essentially, adocumentation tool that supports clinicaldocumentation activities.

Increased Patient Safety

Better Accountability & Billing

Improved Work Efficiency

Unintended Consequences

Inefficiency

Increased Workload

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Studies show that the documentation workload has increased afterusing 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 tofacilitate team collaboration

Though relevant categories of medical records are defined in thehealthcare IT systems, “the practices through which the documentis written, read and used within consultation have been largelyignored.”

It is important to study “the computerized clinical documentation in complex clinicalenvironments, especially the issues of efficiency associated with the EMR usage.”

Problems

Study Goal

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“To examine EMR based documentation in an EmergencyDepartment (ED), with an emphasis on computerizeddocumentation activities in the complex flow of clinicalprocesses. With a focus on clinical workflow issues associatedwith the computerized documentation activities.”

Why Emergency Department (ED)?

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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 theEMR system does or does not support the actual clinical workflow.”

Parallel Documentation Practice: Transitional Artifacts

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This study will reveal a parallel documentation practice that records informalinformation facilitating the flow of clinical work. The informal documentationis considered as Transitional Artifacts that carry the information needed tofacilitate EMR-based documentation.

METHODOLOGY

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Study & Participants

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Observational Study at the Emergency Department(ED) of a large regional hospital located in the westcoast.

57 clinical staff members, including 1 consultingphysician, 11 attending's, 6 residents, 28 registerednurses, and 5 ED technicians.

+ Admitting staff members, case managers, dischargecase planners, as well as social workers, working on thefloor.

”This study consisted of a field observation of the computerized clinical documentation in the ED.”

Emergency Department @ Field Site

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4 major units: a pediatric ED, an urgent care unit, a traumacenter, and the main ED.

The main ED has 2 nursing stations and a MD station surroundedby 12 patient rooms.

The field observation covered the clinical documentation processin patients’ waiting rooms, triages, nursing stations, MDstations, patient rooms and other public areas in the ED.

Main ED Area Map in the EMR

ED Documentation @ Field Site

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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 showwhere patients are on the ED floor.

Only one single path for patient treatmentobserved to illustrate the use of transitionalartifacts (many other paths are possible).

Single path: A patient walks into ED and islater admitted for hospitalization.

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Data and Data Collection

Field Observation

•Examining overall activities related to the ED patient flow with an emphasis on the documentation-relatedactivities, the signoff activities for ED doctors and nurses, the ED admitting and discharging processes, as well as theshift change meetings.

•Both day and night shifts, approximately 50% observation during ED peak times

Data Extraction

•Data related to the ED documentation extracted from notes.

•Data was then sorted & listed by roles of the ED staff and the treatment process.

Analysis

•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.

Verification

•The patterns revealed in the study were further verified with the ED staff to ensure their validities.

” 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.”

FINDINGS OVERVIEW

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ED Workflow

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“The ED documentation handled by four main roles and two information systemsfollowing patients’ treatment process.”

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Happy Thanksgiving

References

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Chen, Y. Documenting transitional information in EMR.Proceedings of the 28th international conference on Humanfactors in computing systems, ACM (2010), 1787–1796.

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