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Experience in implementing inpatient clinical note capture via a provider order entry system.
S Trent Rosenbloom1, Jonathan Grande, Antoine Geissbuhler
1Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA. trent.rosenbloom@vanderbilt.edu
Summary
Computerized note-capture tools saw increased adoption when integrated with existing care provider order entry (CPOE) systems. This demonstrates how established platforms can successfully facilitate the use of new clinical documentation technology.
Area of Science:
- Health Informatics
- Clinical Documentation
- Electronic Health Records
Background:
- Limited adoption of computer-based health documentation tools hinders information gathering and charting efficiency.
- Existing care provider order entry (CPOE) systems offer a potential platform for improved tool integration.
Purpose of the Study:
- To report the development and deployment of a computerized note-capture tool.
- To assess the impact of integrating this tool within an existing CPOE system on user adoption.
Main Methods:
- A computerized note-capture tool was developed and deployed via an established CPOE system at Vanderbilt.
- Usage data (number of users and frequency) was collected between January 1, 1999, and December 31, 2001.
Main Results:
- Significant increase in both the number of users and the frequency of use of the note-capture tool.
- Successful integration within the CPOE environment facilitated user adoption.
Conclusions:
- Existing CPOE systems can effectively promote the adoption of computer-assisted documentation tools.
- This approach offers a viable strategy for enhancing clinical charting efficiency and information management.