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Area of Science:

  • Medical Informatics
  • Health Information Technology
  • Clinical Documentation

Background:

  • Computer-based documentation (CBD) software is integral to electronic health records.
  • Limited adoption of CBD systems may stem from static functionality over 30 years.
  • Early adopters offer insights into improving next-generation CBD systems.

Purpose of the Study:

  • To identify features for next-generation computer-based documentation systems.
  • To improve the adoption rates of electronic health record documentation tools.
  • To survey early adopters of CBD software within the American Medical Informatics Association (AMIA).

Main Methods:

  • A cross-sectional, observational study was conducted online.
  • The study surveyed members of the American Medical Informatics Association (AMIA) clinical working group.
  • A 4-month survey period resulted in a 57% completion rate.

Main Results:

  • CBD tool use was higher (53%) in this population compared to US physician offices.
  • Keyboard and mouse were common, effective data entry methods.
  • CBD improved documentation, information sharing, patient care, and clinician collaboration (P < 0.001).
  • Key absent features include image integration, help functions, and billing generation.

Conclusions:

  • Current CBD systems are successfully used by early adopters, offering advantages over previous methods.
  • Insights from early adopters can guide the development of improved CBD tools.
  • Further research on non-users and failed adopters is needed to address adoption barriers for less computer-literate physicians.