Critical issues in an electronic documentation system.

Area of Science:

• Health Informatics
• Clinical Documentation
• Patient Safety

Background:

• The Veterans Health Administration (VHA) implemented electronic medical records (EMRs) for narrative documentation.
• Efforts were made to simplify report creation within the EMR system.
• While improving readability and access, EMRs may introduce new user hazards.

Purpose of the Study:

• To conduct the initial evaluation of issues related to the creation and use of electronic documentation in the VHA.
• To identify clinician-perceived difficulties and potential harms associated with EMR use.

Main Methods:

• Qualitative analysis of interviews with 88 healthcare providers across 10 VHA primary care sites.
• Interviews were audio-recorded, transcribed, and thematically analyzed.
• Specific questions addressed perceived patient harm from electronic documentation practices.

Main Results:

• Five key themes emerged: information overload, hidden information, lack of trust, communication barriers, and decision-making challenges.
• Three providers reported incidents of patient harm linked to current documentation practices.
• Over 75% of surveyed providers expressed significant distrust in the EMR system.

Conclusions:

• Electronic documentation in the VHA system poses significant challenges for clinicians.
• Issues such as information overload and distrust require attention to mitigate potential risks to patient safety.
• Further research is needed to address these identified problems in electronic health record systems.