Clinical documentation: composition or synthesis?

Area of Science:

• Medical Informatics
• Health Systems Research
• Clinical Documentation

Background:

• Electronic documentation is increasingly prevalent in healthcare.
• Existing electronic health record (EHR) systems may not align with actual clinical documentation workflows.
• Understanding these disconnects is crucial for optimizing healthcare delivery.

Purpose of the Study:

• To investigate the nature of electronic documentation practices among physicians.
• To identify discrepancies between documentation workflows and current EHR system designs.
• To propose improvements for electronic documentation systems.

Main Methods:

• A time-and-motion study was conducted observing resident physicians.
• Practices were analyzed using a commercial EHR system's electronic documentation module.
• Observations took place in a general medicine unit at an academic hospital.

Main Results:

• 96 note-writing sessions and nearly 100 hours of observation were recorded.
• Frequent transitions occurred between documenting and data gathering/review.
• Seven of the top 10 transitions involved documenting and patient data management.

Conclusions:

• Clinical documentation is a synthesis activity, involving data review and judgment summarization.
• Current EHR systems, optimized for composition, create fragmentation and inefficiencies.
• Future systems should facilitate data exploration, search, annotation, and temporal structuring for better support.