activeNotes: Computer-Assisted Creation of Patient Progress Notes.

Area of Science:

• Medical Informatics
• Clinical Documentation Improvement
• Human-Computer Interaction

Background:

• Creating accurate and efficient clinical documentation is crucial in intensive care units (ICUs).
• Existing clinical note systems often face challenges with data integration and user adoption.
• Physicians require tools that streamline the note-creation process while maintaining data accuracy.

Purpose of the Study:

• To present activeNotes, a prototype application designed to support the creation of Critical Care Notes (CCNs).
• To evaluate the usability and perceived value of activeNotes through physician feedback.
• To explore physician preferences for data integration and template use in clinical note generation.

Main Methods:

• Development of activeNotes, a prototype integrating automated patient data retrieval and user-controlled updates/alerts.
• Qualitative user study involving 15 physicians at New York Presbyterian Hospital.
• Collection of physician feedback on the prototype's functionality and potential use.

Main Results:

• Physicians found activeNotes to be a valuable tool for creating both formal and informal clinical notes.
• The integrated automated data retrieval and alert system was perceived as beneficial.
• Surprisingly, physicians expressed interest in creating personalized, physician-specific note templates within activeNotes, contrasting with previous rejections of template-based systems.

Conclusions:

• activeNotes demonstrates potential as a valuable tool for improving clinical note creation in ICUs.
• The integration of automated data and user control enhances the note-creation process.
• Physician desire for personalized templates suggests a need for flexible and customizable documentation solutions.