Int J Med Inform - How physicians document outpatient visit notes in an electronic health record.

Tópicos

{ record(1888) medic(1808) patient(1693) }
{ ehr(2073) health(1662) electron(1139) }
{ state(1844) use(1261) util(961) }
{ method(1219) similar(1157) match(930) }
{ age(1611) year(1155) adult(843) }
{ survey(1388) particip(1329) question(1065) }
{ system(1976) rule(880) can(841) }
{ perform(1367) use(1326) method(1137) }
{ inform(2794) health(2639) internet(1427) }
{ error(1145) method(1030) estim(1020) }
{ extract(1171) text(1153) clinic(932) }
{ patient(1821) servic(1111) care(1106) }
{ decis(3086) make(1611) patient(1517) }
{ take(945) account(800) differ(722) }
{ treatment(1704) effect(941) patient(846) }
{ framework(1458) process(801) describ(734) }
{ problem(2511) optim(1539) algorithm(950) }
{ clinic(1479) use(1117) guidelin(835) }
{ control(1307) perform(991) simul(935) }
{ care(1570) inform(1187) nurs(1089) }
{ data(3963) clinic(1234) research(1004) }
{ perform(999) metric(946) measur(919) }
{ research(1218) medic(880) student(794) }
{ patient(2837) hospit(1953) medic(668) }
{ group(2977) signific(1463) compar(1072) }
{ gene(2352) biolog(1181) express(1162) }
{ use(1733) differ(960) four(931) }
{ drug(1928) target(777) effect(648) }
{ estim(2440) model(1874) function(577) }
{ model(3404) distribut(989) bayesian(671) }
{ can(774) often(719) complex(702) }
{ imag(1947) propos(1133) code(1026) }
{ data(1737) use(1416) pattern(1282) }
{ measur(2081) correl(1212) valu(896) }
{ imag(1057) registr(996) error(939) }
{ bind(1733) structur(1185) ligand(1036) }
{ sequenc(1873) structur(1644) protein(1328) }
{ featur(3375) classif(2383) classifi(1994) }
{ imag(2830) propos(1344) filter(1198) }
{ network(2748) neural(1063) input(814) }
{ imag(2675) segment(2577) method(1081) }
{ patient(2315) diseas(1263) diabet(1191) }
{ studi(2440) review(1878) systemat(933) }
{ motion(1329) object(1292) video(1091) }
{ assess(1506) score(1403) qualiti(1306) }
{ surgeri(1148) surgic(1085) robot(1054) }
{ chang(1828) time(1643) increas(1301) }
{ learn(2355) train(1041) set(1003) }
{ concept(1167) ontolog(924) domain(897) }
{ algorithm(1844) comput(1787) effici(935) }
{ method(1557) propos(1049) approach(1037) }
{ data(1714) softwar(1251) tool(1186) }
{ design(1359) user(1324) use(1319) }
{ model(2220) cell(1177) simul(1124) }
{ general(901) number(790) one(736) }
{ method(984) reconstruct(947) comput(926) }
{ search(2224) databas(1162) retriev(909) }
{ featur(1941) imag(1645) propos(1176) }
{ case(1353) use(1143) diagnosi(1136) }
{ howev(809) still(633) remain(590) }
{ studi(1410) differ(1259) use(1210) }
{ risk(3053) factor(974) diseas(938) }
{ research(1085) discuss(1038) issu(1018) }
{ system(1050) medic(1026) inform(1018) }
{ import(1318) role(1303) understand(862) }
{ model(2341) predict(2261) use(1141) }
{ visual(1396) interact(850) tool(830) }
{ compound(1573) activ(1297) structur(1058) }
{ studi(1119) effect(1106) posit(819) }
{ blood(1257) pressur(1144) flow(957) }
{ spatial(1525) area(1432) region(1030) }
{ health(3367) inform(1360) care(1135) }
{ model(3480) simul(1196) paramet(876) }
{ monitor(1329) mobil(1314) devic(1160) }
{ model(2656) set(1616) predict(1553) }
{ data(2317) use(1299) case(1017) }
{ medic(1828) order(1363) alert(1069) }
{ signal(2180) analysi(812) frequenc(800) }
{ cost(1906) reduc(1198) effect(832) }
{ sampl(1606) size(1419) use(1276) }
{ data(3008) multipl(1320) sourc(1022) }
{ first(2504) two(1366) second(1323) }
{ intervent(3218) particip(2042) group(1664) }
{ activ(1138) subject(705) human(624) }
{ time(1939) patient(1703) rate(768) }
{ use(2086) technolog(871) perceiv(783) }
{ can(981) present(881) function(850) }
{ analysi(2126) use(1163) compon(1037) }
{ health(1844) social(1437) communiti(874) }
{ structur(1116) can(940) graph(676) }
{ high(1669) rate(1365) level(1280) }
{ cancer(2502) breast(956) screen(824) }
{ use(976) code(926) identifi(902) }
{ result(1111) use(1088) new(759) }
{ implement(1333) system(1263) develop(1122) }
{ process(1125) use(805) approach(778) }
{ activ(1452) weight(1219) physic(1104) }
{ method(1969) cluster(1462) data(1082) }
{ method(2212) result(1239) propos(1039) }
{ detect(2391) sensit(1101) algorithm(908) }

Resumo

CKGROUND: Clinical documentation, an essential process within electronic health records (EHRs), takes a significant amount of clinician time. How best to optimize documentation methods to deliver effective care remains unclear.OBJECTIVE: We evaluated whether EHR visit note documentation method was influenced by physician or practice characteristics, and the association of physician satisfaction with an EHR notes module.MEASUREMENTS: We surveyed primary care physicians (PCPs) and specialists, and used EHR and provider data to perform a multinomial logistic regression of visit notes from 2008. We measured physician documentation method use and satisfaction with an EHR notes module and determined the relationship between method and physician and practice characteristics.RESULTS: Of 1088 physicians, 85% used a single method to document the majority of their visits. PCPs predominantly documented using templates (60%) compared to 34% of specialists, while 38% of specialists predominantly dictated. Physicians affiliated with academic medical centers (OR 1.96, CI (1.23, 3.12)), based at a hospital (OR 1.57, 95% CI (1.04, 2.36)) and using the EHR for longer (OR 1.13, 95% CI (1.03, 1.25)) were more likely to dictate than use templates. Most physicians of 383 survey responders were satisfied with the EHR notes module, regardless of their preferred documentation method.CONCLUSIONS: Physicians predominantly utilized a single method of visit note documentation and were satisfied with their approach, but the approaches they chose varied. Demographic characteristics were associated with preferred documentation method. Further research should focus on why variation exists, and the quality of the documentation resulting from different methods used.

Resumo Limpo

ckground clinic document essenti process within electron health record ehr take signific amount clinician time best optim document method deliv effect care remain unclearobject evalu whether ehr visit note document method influenc physician practic characterist associ physician satisfact ehr note modulemeasur survey primari care physician pcps specialist use ehr provid data perform multinomi logist regress visit note measur physician document method use satisfact ehr note modul determin relationship method physician practic characteristicsresult physician use singl method document major visit pcps predomin document use templat compar specialist specialist predomin dictat physician affili academ medic center ci base hospit ci use ehr longer ci like dictat use templat physician survey respond satisfi ehr note modul regardless prefer document methodconclus physician predomin util singl method visit note document satisfi approach approach chose vari demograph characterist associ prefer document method research focus variat exist qualiti document result differ method use

Resumos Similares

J Med Syst - Evaluation of the medical records system in an upcoming teaching hospital-a project for improvisation. ( 0,829844847266318 )
J Med Syst - Use and satisfaction with electronic health record by primary care physicians in a health district in Brazil. ( 0,764726036550565 )
Int J Med Inform - The trends in EMR and CPOE adoption in Japan under the national strategy. ( 0,744456394507834 )
AMIA Annu Symp Proc - Evaluation of HL7 v2.5.1 electronic case reports transmitted from a healthcare enterprise to public health. ( 0,729557076949049 )
BMC Med Inform Decis Mak - Impact of a computerized system for evidence-based diabetes care on completeness of records: a before-after study. ( 0,72646088508543 )
J Am Med Inform Assoc - Method of electronic health record documentation and quality of primary care. ( 0,725748326970634 )
Perspect Health Inf Manag - Workflow and electronic health records in small medical practices. ( 0,723301711993909 )
Perspect Health Inf Manag - Lessons learned from implementation of voice recognition for documentation in the military electronic health record system. ( 0,710334424297373 )
J. Med. Internet Res. - Characteristics of patient portals developed in the context of health information exchanges: early policy effects of incentives in the meaningful use program in the United States. ( 0,702249462243721 )
J Am Med Inform Assoc - Factors associated with difficult electronic health record implementation in office practice. ( 0,700897180121897 )
Appl Clin Inform - Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes. ( 0,690396272502044 )
Telemed J E Health - Teledentistry in practice: literature review. ( 0,686375929279865 )
Appl Clin Inform - An analysis of free-text alcohol use documentation in the electronic health record: early findings and implications. ( 0,686042236341918 )
Healthc (Amst) - Do family physicians electronic health records support meaningful use? ( 0,684305344655924 )
J Am Med Inform Assoc - Data from clinical notes: a perspective on the tension between structure and flexible documentation. ( 0,674845537033402 )
J Am Med Inform Assoc - Use of electronic medical records differs by specialty and office settings. ( 0,671673068278395 )
BMC Med Inform Decis Mak - Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers. ( 0,669917769550518 )
AMIA Annu Symp Proc - An integrated billing application to streamline clinician workflow. ( 0,669913269574459 )
J Am Med Inform Assoc - The effect of electronic medical record system sophistication on preventive healthcare for women. ( 0,669054852635911 )
J Am Med Inform Assoc - Patient access to medical records and healthcare outcomes: a systematic review. ( 0,66787565605388 )
J Am Med Inform Assoc - Phased implementation of electronic health records through an office of clinical transformation. ( 0,666440354061457 )
BMC Med Inform Decis Mak - Use of a health information exchange system in the emergency care of children. ( 0,662186534764849 )
J Med Syst - Usability evaluation of paper-based Hajji Health Record format. ( 0,659788176723363 )
Appl Clin Inform - Clinician perceptions of pediatric growth chart use and electronic health records in Kentucky. ( 0,655375509156327 )
Int J Med Inform - Socio-technical considerations in epilepsy electronic patient record implementation. ( 0,649022369676591 )
AMIA Annu Symp Proc - A qualitative analysis of EHR clinical document synthesis by clinicians. ( 0,648994862434204 )
J Am Med Inform Assoc - Agreement between common goals discussed and documented in the ICU. ( 0,648127801442584 )
J Am Med Inform Assoc - Consumer experience with and attitudes toward health information technology: a nationwide survey. ( 0,64675923427743 )
J Med Syst - A novel system architecture for the national integration of electronic health records: a semi-centralized approach. ( 0,645333333545022 )
J Clin Monit Comput - Implementation of a standards-based anaesthesia record compliant with the health level 7 (HL7) clinical document architecture (CDA). ( 0,642597343490271 )
Appl Clin Inform - A pilot trial of a computerized renal template note to improve resident knowledge and documentation of kidney disease. ( 0,642529544403483 )
J Biomed Inform - Development of a clinician reputation metric to identify appropriate problem-medication pairs in a crowdsourced knowledge base. ( 0,637543548825535 )
J. Med. Internet Res. - Use of an electronic patient portal among the chronically ill: an observational study. ( 0,635600664928671 )
J Am Med Inform Assoc - Same organization, same electronic health records (EHRs) system, different use: exploring the linkage between practice member communication patterns and EHR use patterns in an ambulatory care setting. ( 0,635548850885093 )
Appl Clin Inform - Effects of automated immunization registry reporting via an electronic health record deployed in community practice settings. ( 0,635232880187286 )
Int J Med Inform - An investigation of the efficacy of electronic consenting interfaces of research permissions management system in a hospital setting. ( 0,633496053802916 )
J Med Syst - Development of fundamental infrastructure for nationwide EHR in Japan. ( 0,626338665887802 )
J Am Med Inform Assoc - Evaluating and classifying the readiness of technology specifications for national standardization. ( 0,625029571638904 )
Comput Methods Programs Biomed - The relationship between usage intention and adoption of electronic health records at primary care clinics. ( 0,625015655602657 )
J Am Med Inform Assoc - Clinical documentation: composition or synthesis? ( 0,624853228368407 )
Int J Med Inform - National questionnaire study on clinical ICT systems proofs: physicians suffer from poor usability. ( 0,624843633936846 )
Appl Clin Inform - Utilizing an electronic health record system to improve vaccination coverage in children. ( 0,624215031492686 )
Int J Med Inform - Collaboration in electronic medical evidence development: a case study of the Social Security Administration's MEGAHIT System. ( 0,623347071161215 )
AMIA Annu Symp Proc - Implementing the IT infrastructure for health reform: adoption of health IT among patient-centered medical home practices. ( 0,621788538764955 )
J Am Med Inform Assoc - The Hub Population Health System: distributed ad hoc queries and alerts. ( 0,621391009881384 )
Perspect Health Inf Manag - Electronic medical record systems in critical access hospitals: leadership perspectives on anticipated and realized benefits. ( 0,620849343453487 )
Methods Inf Med - Survey on medical records and EHR in Asia-Pacific region: languages, purposes, IDs and regulations. ( 0,620474896913942 )
J Am Med Inform Assoc - How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use. ( 0,619200970577078 )
AMIA Annu Symp Proc - Lexical concept distribution reflects clinical practice. ( 0,617787147366452 )
Int J Med Inform - Separate may not be equal: a preliminary investigation of clinical correlates of electronic psychiatric record accessibility in academic medical centers. ( 0,614997134100496 )
Int J Med Inform - The perception of medical professionals and medical students on the usefulness of an emergency medical card and a continuity of care report in enhancing continuity of care. ( 0,614034663832408 )
Int J Med Inform - Physicians' potential use and preferences related to health information exchange. ( 0,613236814697857 )
Int J Med Inform - Structured electronic operative reporting: comparison with dictation in kidney cancer surgery. ( 0,612894525059653 )
Appl Clin Inform - Rapid implementation of inpatient electronic physician documentation at an academic hospital. ( 0,611431098129065 )
BMC Med Inform Decis Mak - Beyond the threshold: real-time use of evidence in practice. ( 0,610991168784396 )
Int J Med Inform - Concept and implementation of a computer-based reminder system to increase completeness in clinical documentation. ( 0,610250626430708 )
AMIA Annu Symp Proc - You can lead a horse to water: physicians' responses to clinical reminders. ( 0,610167752312827 )
Health Informatics J - Clinical Document Architecture integration system to support patient referral and reply letters. ( 0,609415848360325 )
AMIA Annu Symp Proc - Potential value of health information exchange for people with epilepsy: crossover patterns and missing clinical data. ( 0,609025243415495 )
J Biomed Inform - Implementing standards for the interoperability among healthcare providers in the public regionalized Healthcare Information System of the Lombardy Region. ( 0,608053704668891 )
AMIA Annu Symp Proc - Who said it? Establishing professional attribution among authors of Veterans' Electronic Health Records. ( 0,606449764076296 )
AMIA Annu Symp Proc - Continuity of Care Document (CCD) Enables Delivery of Medication Histories to the Primary Care Clinician. ( 0,606020184648642 )
J Med Syst - Opioid prescribing by physicians with and without electronic health records. ( 0,604308284020194 )
Med Decis Making - Natural language processing improves identification of colorectal cancer testing in the electronic medical record. ( 0,603524181334975 )
J Am Med Inform Assoc - Lessons learned from the introduction of an electronic safety net to enhance test result management in an Australian mothers' hospital. ( 0,602771330619301 )
Appl Clin Inform - Relationship between documentation method and quality of chronic disease visit notes. ( 0,600512936668523 )
J Am Med Inform Assoc - A framework for assessing patient crossover and health information exchange value. ( 0,600231469390907 )
J Biomed Inform - Implementations of the HL7 Context-Aware Knowledge Retrieval (Infobutton) Standard: challenges, strengths, limitations, and uptake. ( 0,599336774477714 )
AMIA Annu Symp Proc - Physician Attitudes about Patient-Facing Information Displays at an Urban Emergency Department. ( 0,598882038624823 )
J Med Syst - Factors related to health information exchange participation and use. ( 0,597609751467388 )
Perspect Health Inf Manag - Electronic health record adoption and use by Nebraska pharmacists. ( 0,597484573215667 )
Appl Clin Inform - Physician specialty and variations in adoption of electronic health records. ( 0,597234078236261 )
AMIA Annu Symp Proc - Comparing content coverage in medical curriculum to trainee-authored clinical notes. ( 0,596645166088624 )
Int J Med Inform - Supporting medical communication for older patients with a shared touch-screen computer. ( 0,593027676711681 )
Appl Clin Inform - Determining primary care physician information needs to inform ambulatory visit note display. ( 0,590858227204163 )
Appl Clin Inform - Transitioning from a legacy EHR to a commercial, vendor-supplied, EHR: one academic health system's experience. ( 0,589497145409888 )
Int J Med Inform - Physician experiences transitioning between an older versus newer electronic health record for electronic prescribing. ( 0,589457892058503 )
Int J Med Inform - Is email an effective method for hospital discharge communication? A randomized controlled trial to examine delivery of computer-generated discharge summaries by email, fax, post and patient hand delivery. ( 0,588022831461875 )
Comput Methods Programs Biomed - Comparison of documentation time between an electronic and a paper-based record system by optometrists at an eye hospital in south India: a time-motion study. ( 0,588014386222647 )
J Med Syst - An assessment of patient safety in acupuncture process under EMR support. ( 0,586970284627516 )
AMIA Annu Symp Proc - Capture of osteoporosis and fracture information in an electronic medical record database from primary care. ( 0,584571636838794 )
J Med Syst - Performance assessment of EMR systems based on post-relational database. ( 0,584188796708432 )
Int J Med Inform - Views on health information sharing and privacy from primary care practices using electronic medical records. ( 0,583958494486701 )
J Am Med Inform Assoc - Electronic health records improve clinical note quality. ( 0,58183487025708 )
Int J Med Inform - The effects of an electronic medical record on the completeness of documentation in the anesthesia record. ( 0,581416685824634 )
AMIA Annu Symp Proc - Validation and enhancement of a computable medication indication resource (MEDI) using a large practice-based dataset. ( 0,580805298054219 )
Int J Med Inform - Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care. ( 0,580565624128237 )
J Am Med Inform Assoc - Electronic medical record use in pediatric primary care. ( 0,579812654427903 )
BMC Med Inform Decis Mak - Health Professionals' readiness to implement electronic medical record system at three hospitals in Ethiopia: a cross sectional study. ( 0,579806859087281 )
Int J Med Inform - Analysis and evaluation of the Electronic Health Record standard in China: a comparison with the American national standard ASTM E 1384. ( 0,579797133694496 )
AMIA Annu Symp Proc - The physical attractiveness of electronic physician notes. ( 0,579171421618073 )
J Am Med Inform Assoc - Data standards to support health information exchange between poison control centers and emergency departments. ( 0,578300413294309 )
J Med Syst - Factors associated with health information exchange system usage in a safety-net ambulatory care clinic setting. ( 0,577088755298657 )
BMC Med Inform Decis Mak - On the usage of health records for the design of Virtual Patients: a systematic review. ( 0,576595535636792 )
J Am Med Inform Assoc - Design and evaluation of a wireless electronic health records system for field care in mass casualty settings. ( 0,576178369872966 )
J Am Med Inform Assoc - A typology of electronic health record workarounds in small-to-medium size primary care practices. ( 0,574773955008248 )
AMIA Annu Symp Proc - Enabling locally-developed content for access through the infobutton by means of automated concept annotation. ( 0,57374362128934 )
Comput. Biol. Med. - Clinicians' evaluation of computer-assisted medication summarization of electronic medical records. ( 0,57014843337346 )
AMIA Annu Symp Proc - Assessing readiness for meeting meaningful use: identifying electronic health record functionality and measuring levels of adoption. ( 0,568880740401897 )
AMIA Annu Symp Proc - Electronic laboratory data quality and the value of a health information exchange to support public health reporting processes. ( 0,568696821305444 )