Efficiency strategies for facilitating computerized clinical documentation in ambulatory care

Area of Science:

• Health Informatics
• Human Factors Engineering
• Medical Documentation

Background:

• Electronic health records (EHRs) have increased documentation burdens for healthcare providers.
• Efficient clinical documentation is crucial for patient care and provider workload management.

Purpose of the Study:

• To identify and analyze efficiency strategies used by ambulatory care providers for completing EHR progress notes.
• To understand how providers adapt their workflows to manage EHR documentation demands.

Main Methods:

• Ethnographic observations and semi-structured interviews with 22 ambulatory care providers.
• Qualitative coding of observation notes and interview transcripts to identify documentation strategies.

Main Results:

• Common strategies include using paper artifacts, electronic templates, shorthand, copy-pasting from previous notes, direct data entry during encounters, memory recall, and pre-populating notes.
• These strategies represent adaptations to optimize the completion of EHR progress notes.

Conclusions:

• Provider-identified strategies offer insights into streamlining clinical documentation processes.
• Findings have implications for designing more efficient EHR systems and implementing human factors-informed workload management strategies.