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Transition from paper to electronic inpatient physician notes
Thomas H Payne1, Aharon E tenBroek, Grant S Fletcher
1University of Washington, Seattle, Washington 98104-2499, USA. tpayne@u.washington.edu
Journal of the American Medical Informatics Association : JAMIA
|January 13, 2010
Summary
UW Medicine transitioned to electronic physician inpatient notes, improving data access and patient care. Challenges like note entry time and EMR usability persist but are being addressed.
Area of Science:
- Health Informatics
- Clinical Documentation
- Hospital Operations
Background:
- Academic medical centers are shifting from paper-based to electronic health records.
- Improving access to patient information and streamlining clinical workflows are key goals.
Purpose of the Study:
- To describe the transition from paper to electronic physician inpatient notes at UW Medicine teaching hospitals.
- To identify drivers, barriers, and outcomes of this EMR implementation.
Main Methods:
- Enhancing workstation availability and wireless infrastructure to support the electronic medical record (EMR).
- Implementing data-rich templates tailored to rounding workflows and simplifying login procedures.
- A 2-year transition period for nearly all physician notes to be entered electronically.
Main Results:
- Nearly all physician inpatient notes (approx. 1500/day) are now electronic.
- Key drivers included unifying medical records across disciplines.
- Barriers such as note entry time were mitigated through workflow-specific templates and simplified login.
Conclusions:
- The transition to electronic physician notes is largely successful and considered valuable for patient care and hospital operations.
- Ongoing challenges include optimizing note entry time and improving EMR usability for note comprehension and retrieval.
- Continued refinement of the EMR system is necessary to fully address remaining challenges.
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