J Am Med Inform Assoc - Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators.

Tópicos

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

JECTIVE: Clinical documentation is central to the medical record and so to a range of healthcare and business processes. As electronic health record adoption expands, computerized provider documentation (CPD) is increasingly the primary means of capturing clinical documentation. Previous CPD studies have focused on particular stakeholder groups and sites, often limiting their scope and conclusions. To address this, we studied multiple stakeholder groups from multiple sites across the USA.METHODS: We conducted 14 focus groups at five Department of Veterans Affairs facilities with 129 participants (54 physicians or practitioners, 34 nurses, and 37 administrators). Investigators qualitatively analyzed resultant transcripts, developed categories linked to the data, and identified emergent themes.RESULTS: Five major themes related to CPD emerged: communication and coordination; control and limitations in expressivity; information availability and reasoning support; workflow alteration and disruption; and trust and confidence concerns. The results highlight that documentation intertwines tightly with clinical and administrative workflow. Perceptions differed between the three stakeholder groups but remained consistent within groups across facilities.CONCLUSIONS: CPD has dramatically changed documentation processes, impacting clinical understanding, decision-making, and communication across multiple groups. The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows. Current CPD systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated 'paper-chart' paradigm. These findings should inform those implementing CPD systems now and future plans for more effective CPD systems.

Resumo Limpo

jectiv clinic document central medic record rang healthcar busi process electron health record adopt expand computer provid document cpd increas primari mean captur clinic document previous cpd studi focus particular stakehold group site often limit scope conclus address studi multipl stakehold group multipl site across usamethod conduct focus group five depart veteran affair facil particip physician practition nurs administr investig qualit analyz result transcript develop categori link data identifi emerg themesresult five major theme relat cpd emerg communic coordin control limit express inform avail reason support workflow alter disrupt trust confid concern result highlight document intertwin tight clinic administr workflow percept differ three stakehold group remain consist within group across facilitiesconclus cpd dramat chang document process impact clinic understand decisionmak communic across multipl group need easi rapid yet structur constrain document often conflict need high reliabl retriev inform support clinic reason workflow current cpd system better paper overal often meet need user part base outdat paperchart paradigm find inform implement cpd system now futur plan effect cpd system

Resumos Similares

Int J Med Inform - Evaluation of the national nursing model and four nursing documentation systems in Finland--lessons learned and directions for the future. ( 0,821956614124243 )
Int J Med Inform - A model of awareness to enhance our understanding of interprofessional collaborative care delivery and health information system design to support it. ( 0,82108098424262 )
J Am Med Inform Assoc - Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. ( 0,803335636927768 )
Int J Med Inform - The impact of medical record technologies on collaboration in emergency medicine. ( 0,781598422771183 )
J Am Med Inform Assoc - The impact of PACS on clinician work practices in the intensive care unit: a systematic review of the literature. ( 0,769318366237736 )
Int J Med Inform - Health information exchange interventions can enhance quality and continuity of HIV care. ( 0,768052032453058 )
J Am Med Inform Assoc - A system dynamics evaluation model: implementation of health information exchange for public health reporting. ( 0,767987616083048 )
Healthc (Amst) - Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics. ( 0,764270809940122 )
Int J Med Inform - Use of electronic information systems in nursing management. ( 0,762796538888614 )
BMC Med Inform Decis Mak - The status of IT service management in health care - ITIL? in selected European countries. ( 0,761688176027662 )
Healthc (Amst) - Doubling down: Lessons learned from building a new electronic health record as part of primary care practice redesign. ( 0,75772850137727 )
BMC Med Inform Decis Mak - Improving the effectiveness of electronic health record-based referral processes. ( 0,757434535958178 )
Appl Clin Inform - An evaluation of the usability of a computerized decision support system for nursing homes. ( 0,753854017352816 )
Healthc (Amst) - Implementing a patient centered medical home in the Veterans health administration: Perspectives of primary care providers. ( 0,753168621568026 )
J Biomed Inform - Bridging gaps in handoffs: a continuity of care based approach. ( 0,752177996545122 )
BMC Med Inform Decis Mak - Validation of the Work Observation Method By Activity Timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study. ( 0,745416135994327 )
Health Informatics J - The coordination hub: Toward patient-centered and collaborative care processes. ( 0,740658453346771 )
Int J Med Inform - Can technology change the work of nurses? Evaluation of a drug monitoring system for ambulatory chronic disease patients. ( 0,738687272137439 )
BMC Med Inform Decis Mak - National survey focusing on the crucial information needs of intensive care charge nurses and intensivists: same goal, different demands. ( 0,737270592286167 )
Int J Med Inform - Exploring practice variation in preventive pressure-ulcer care using data from a clinical data repository. ( 0,737221096541734 )
Int J Med Inform - Using Cognitive Work Analysis to fit decision support tools to nurse managers' work flow. ( 0,734785173373857 )
J Am Med Inform Assoc - Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness. ( 0,734668058305331 )
Int J Med Inform - Guidelines for maternal and neonatal point of care: needs of and attitudes towards a computerized clinical decision support system in rural Burkina Faso. ( 0,73427615717285 )
Int J Med Inform - Does e-pain plan improve management of sickle cell disease associated vaso-occlusive pain crisis? a mixed methods evaluation. ( 0,733033019169511 )
Int J Med Inform - The effects of EMR deployment on doctors' work practices: a qualitative study in the emergency department of a teaching hospital. ( 0,732585919288947 )
AMIA Annu Symp Proc - Examining the Multi-level Fit between Work and Technology in a Secure Messaging Implementation. ( 0,732566751701785 )
Int J Med Inform - Managing variations from surgical care plans: challenges for coordination. ( 0,732340644891578 )
BMC Med Inform Decis Mak - Quality of prenatal and maternal care: bridging the know-do gap (QUALMAT study): an electronic clinical decision support system for rural Sub-Saharan Africa. ( 0,730274487023105 )
J Am Med Inform Assoc - Towards public health decision support: a systematic review of bidirectional communication approaches. ( 0,729683411342299 )
AMIA Annu Symp Proc - Development of a nursing handoff tool: a web-based application to enhance patient safety. ( 0,728041584957209 )
Healthc (Amst) - When scaling prevention means scaling demand: Voluntary medical male circumcision in Nyanza Province, Kenya. ( 0,727079049957843 )
Int J Med Inform - Multi-disciplinary communication networks for skin risk assessment in nursing homes with high IT sophistication. ( 0,725736799206196 )
J Med Syst - Understanding critical barriers to implementing a clinical information system in a nursing home through the lens of a socio-technical perspective. ( 0,719346559549849 )
J. Med. Internet Res. - Aligning medication reconciliation and secure messaging: qualitative study of primary care providers' perspectives. ( 0,718667173791174 )
Health Informatics J - Accessibility, usability, and usefulness of a Web-based clinical decision support tool to enhance provider-patient communication around Self-management TO Prevent (STOP) Stroke. ( 0,717306037685227 )
BMC Med Inform Decis Mak - The role of ICT in supporting disruptive innovation: a multi-site qualitative study of nurse practitioners in emergency departments. ( 0,716704991537909 )
Telemed J E Health - Task-technology fit of video telehealth for nurses in an outpatient clinic setting. ( 0,716332946888432 )
Int J Med Inform - Different usage of the same oncology information system in two hospitals in Sydney--lessons go beyond the initial introduction. ( 0,715977954553181 )
AMIA Annu Symp Proc - Falling through the cracks: information breakdowns in critical care handoff communication. ( 0,714966672647388 )
J Am Med Inform Assoc - Patient-centered care requires a patient-oriented workflow model. ( 0,714770491616346 )
Int J Med Inform - The importance of the verbal shift handover report: a multi-site case study. ( 0,713679772097407 )
Int J Med Inform - Going paperless at the emergency department: a socio-technical study of an information system for patient tracking. ( 0,711656374489971 )
BMC Med Inform Decis Mak - Successful implementation of new technologies in nursing care: a questionnaire survey of nurse-users. ( 0,711104337673849 )
BMC Med Inform Decis Mak - Qualitative evaluation of a diabetes electronic decision support tool: views of users. ( 0,709154078497356 )
J Biomed Inform - Computer-interpretable clinical guidelines: a methodological review. ( 0,707440092287546 )
Int J Med Inform - Issues and questions to consider in implementing secure electronic patient-provider web portal communications systems. ( 0,704438723669198 )
Int J Med Inform - Perceptions of urgency: defining the gap between what physicians and nurses perceive to be an urgent issue. ( 0,702713898289649 )
Inform Health Soc Care - Information exchange between registered nurses and district nurses during the discharge planning process: cross-sectional analysis of survey data. ( 0,701644884067015 )
Int J Med Inform - Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff? ( 0,701281674814411 )
Telemed J E Health - Implementing home blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons learned. ( 0,701249790756142 )
J Innov Health Inform - Using information to deliver safer care: a mixed-methods study exploring general practitioners' information needs in North West London primary care. ( 0,700959728876695 )
AMIA Annu Symp Proc - Clinical Workflow Observations to Identify Opportunities for Nurse, Physicians and Patients to Share a Patient-centered Plan of Care. ( 0,700302934588773 )
Int J Med Inform - Evaluation of a comprehensive EHR based on the DeLone and McLean model for IS success: approach, results, and success factors. ( 0,69969219745831 )
BMC Med Inform Decis Mak - A study of clinical and information management processes in the surgical pre-assessment clinic. ( 0,698594133549449 )
Int J Med Inform - Effect of a nursing information system on the quality of information processing in nursing: An evaluation study using the HIS-monitor instrument. ( 0,694029627121991 )
Int J Med Inform - Barriers and facilitators to the use of computer-based intensive insulin therapy. ( 0,692859638119452 )
J Biomed Inform - Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: a sociotechnical analysis. ( 0,691482152227598 )
BMC Med Inform Decis Mak - Participatory eHealth development to support nurses in antimicrobial stewardship. ( 0,690749688344806 )
Appl Clin Inform - Insight into the sharing of medical images: physician, other health care providers, and staff experience in a variety of medical settings. ( 0,68961281872008 )
Int J Med Inform - The benefits of introducing electronic health records in residential aged care facilities: a multiple case study. ( 0,68957859945232 )
Telemed J E Health - A systematic review of clinician and staff views on the acceptability of incorporating remote monitoring technology into primary care. ( 0,689297494427674 )
Int J Med Inform - Organizational routines, innovation, and flexibility: the application of narrative networks to dynamic workflow. ( 0,687149651970312 )
J Biomed Inform - Proclets in healthcare. ( 0,684168748865627 )
Healthc (Amst) - Flexible implementation and integration of new team members to support patient-centered care. ( 0,682718109307335 )
Health Informatics J - Using integrated bio-physiotherapy informatics in home health-care settings: A qualitative analysis of a point-of-care decision support system. ( 0,681725373231913 )
BMC Med Inform Decis Mak - A qualitative evaluation of general practitioners' views on protocol-driven eReferral in Scotland. ( 0,679637526670892 )
J. Med. Internet Res. - An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study. ( 0,679013061889165 )
AMIA Annu Symp Proc - Describing the Clinical Communication Space through a Model of Common Ground: 'you don't know what you don't know'. ( 0,677743175023198 )
Inform Health Soc Care - Information practices of health care professionals related to patient discharge from hospital. ( 0,676701191710485 )
AMIA Annu Symp Proc - To talk or not to talk: exploring culturally diverse patients' health information communication choices. ( 0,676351781324241 )
Int J Med Inform - Employing the FITT framework to explore HIV case managers' perceptions of two electronic clinical data (ECD) summary systems. ( 0,676266851016338 )
Int J Med Inform - Lost in translation: the challenges of seamless integration in nursing practices. ( 0,676233533624658 )
Int J Med Inform - Towards an understanding of the information dynamics of the handover process in aged care settings--a prerequisite for the safe and effective use of ICT. ( 0,675395755741272 )
Appl Clin Inform - An e-health decision support system for improving compliance of health workers to the maternity care protocols in South Africa. ( 0,674417658075929 )
AMIA Annu Symp Proc - Coordination of care for complex pediatric patients: perspectives from providers and parents. ( 0,674327398653963 )
AMIA Annu Symp Proc - Clinical decision support for whole genome sequence information leveraging a service-oriented architecture: a prototype. ( 0,6736076782389 )
Perspect Health Inf Manag - Electronic health records: what are the most important barriers? ( 0,673108306775433 )
AMIA Annu Symp Proc - Support for contextual control in primary care: a qualitative analysis. ( 0,671987280567321 )
Appl Clin Inform - A case report in health information exchange for inter-organizational patient transfers. ( 0,670704577576389 )
BMC Med Inform Decis Mak - Staff experiences within the implementation of computer-based nursing records in residential aged care facilities: a systematic review and synthesis of qualitative research. ( 0,670075892900631 )
Methods Inf Med - Real-time feedback on nonverbal clinical communication. Theoretical framework and clinician acceptance of ambient visual design. ( 0,667950959572781 )
Comput Methods Programs Biomed - LabPush: a pilot study of providing remote clinics with laboratory results via short message service (SMS) in Swaziland, Africa - a qualitative study. ( 0,665706020396195 )
Appl Clin Inform - CAH to CAH: EHR implementation advice to critical access hospitals from peer experts and other key informants. ( 0,664355453125662 )
BMC Med Inform Decis Mak - From design to implementation--the Joint Asia Diabetes Evaluation (JADE) program: a descriptive report of an electronic web-based diabetes management program. ( 0,662929203956157 )
J Am Med Inform Assoc - The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals. ( 0,662701689830897 )
J Am Med Inform Assoc - Content and functional specifications for a standards-based multidisciplinary rounding tool to maintain continuity across acute and critical care. ( 0,662510220069347 )
BMC Med Inform Decis Mak - What is needed to implement a computer-assisted health risk assessment tool? An exploratory concept mapping study. ( 0,661884361314765 )
Telemed J E Health - Home telehealth: facilitators, barriers, and impact of nurse support among high-risk dialysis patients. ( 0,661324403180772 )
AMIA Annu Symp Proc - A mixed methods approach for measuring the impact of delivery-centric interventions on clinician workflow. ( 0,661294360197976 )
BMC Med Inform Decis Mak - Health communication in primary health care -a case study of ICT development for health promotion. ( 0,657753746849918 )
AMIA Annu Symp Proc - A Framework for Incorporating Patient Preferences to Deliver Participatory Medicine via Interdisciplinary Healthcare Teams. ( 0,656716616000522 )
BMC Med Inform Decis Mak - Implementation of an integrated preoperative care pathway and regional electronic clinical portal for preoperative assessment. ( 0,656447505360233 )
J Med Syst - A usability framework for speech recognition technologies in clinical handover: a pre-implementation study. ( 0,655142907076044 )
Appl Clin Inform - Clinician preferences for verbal communication compared to EHR documentation in the ICU. ( 0,654866311049675 )
Health Info Libr J - Information needs of clinicians and non-clinicians in the Emergency Department: a qualitative study. ( 0,652780561742484 )
Int J Med Inform - An exploration of the impact of computerized patient documentation on clinical collaboration. ( 0,652654357978685 )
Telemed J E Health - International trauma teleconference: evaluating trauma care and facilitating quality improvement. ( 0,651868656855147 )
Int J Med Inform - Nurses' experiences of using an interactive tailored patient assessment tool one year past implementation. ( 0,64881111763912 )
Int J Med Inform - Preparing the ground for the 'paperless hospital': a case study of medical records management in a UK outpatient services department. ( 0,64427817351419 )
Health Informatics J - Sources of variation in primary care clinical workflow: implications for the design of cognitive support. ( 0,644103641582573 )