Ho Y-X, Gadd C S, Kohorst K L, Rosenbloom S T
Department of Biomedical Informatics, Vanderbilt University School of Medicine , Nashville, TN.
Department of Anesthesiology, Vanderbilt University Medical Center , Nashville, TN.
Appl Clin Inform. 2014 Feb 26;5(1):153-68. doi: 10.4338/ACI-2013-10-RA-0081. eCollection 2014.
An important challenge for biomedical informatics researchers is determining the best approach for healthcare providers to use when generating clinical notes in settings where electronic health record (EHR) systems are used. The goal of this qualitative study was to explore healthcare providers' and administrators' perceptions about the purpose of clinical documentation and their own documentation practices.
We conducted seven focus groups with a total of 46 subjects composed of healthcare providers and administrators to collect knowledge, perceptions and beliefs about documentation from those who generate and review notes, respectively. Data were analyzed using inductive analysis to probe and classify impressions collected from focus group subjects.
We observed that both healthcare providers and administrators believe that documentation serves five primary domains: clinical, administrative, legal, research, education. These purposes are tied closely to the nature of the clinical note as a document shared by multiple stakeholders, which can be a source of tension for all parties who must use the note. Most providers reported using a combination of methods to complete their notes in a timely fashion without compromising patient care. While all administrators reported relying on computer-based documentation tools to review notes, they expressed a desire for a more efficient method of extracting relevant data.
Although clinical documentation has utility, and is valued highly by its users, the development and successful adoption of a clinical documentation tool largely depends on its ability to be smoothly integrated into the provider's busy workflow, while allowing the provider to generate a note that communicates effectively and efficiently with multiple stakeholders.
生物医学信息学研究人员面临的一项重要挑战是，确定在使用电子健康记录（EHR）系统的环境中，医疗保健提供者生成临床记录时的最佳方法。这项定性研究的目的是探讨医疗保健提供者和管理人员对临床文档目的的看法以及他们自己的文档记录做法。
我们开展了7个焦点小组，共有46名由医疗保健提供者和管理人员组成的受试者，分别从生成和审核记录的人员那里收集有关文档记录的知识、看法和信念。使用归纳分析对数据进行分析，以探究和分类从焦点小组受试者那里收集到的印象。
我们观察到，医疗保健提供者和管理人员都认为文档记录服务于五个主要领域：临床、管理、法律、研究、教育。这些目的与临床记录作为多个利益相关者共享的文档的性质紧密相关，这可能会给所有必须使用该记录的各方带来紧张关系。大多数提供者报告说，他们使用多种方法相结合，以便在不影响患者护理的情况下及时完成记录。虽然所有管理人员都报告依赖基于计算机的文档工具来审核记录，但他们表示希望有一种更有效的方法来提取相关数据。
虽然临床文档记录有用，且受到用户高度重视，但临床文档工具的开发和成功采用在很大程度上取决于其能否顺利融入提供者繁忙的工作流程，同时使提供者能够生成一份与多个利益相关者进行有效沟通的记录。
