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Electronic Health Record Documentation Times among Emergency Medicine Trainees
Scott Crawford1, Igor Kushner2, Radosveta Wells1
1Texas Tech University Health Sciences Center El Paso in El Paso, TX.
Perspectives in Health Information Management
|February 16, 2019
Summary
Physician documentation time in electronic health records (EHRs) was compared between two systems. Trainee experience level significantly impacted documentation efficiency, with more advanced trainees faster on the Cerner system.
Area of Science:
- Medical Informatics
- Healthcare Management
- Clinical Documentation
Background:
- Physicians dedicate substantial time to patient encounter documentation via electronic health records (EHRs).
- Despite widespread adoption driven by Meaningful Use guidelines, EHRs have not demonstrably reduced physician documentation time.
- Existing research lacks comparative analysis of documentation efficiency across different EHR systems.
Purpose of the Study:
- To compare the time required for emergency department (ED) note completion between two distinct EHR systems.
- To evaluate the influence of trainee level and system experience on documentation efficiency.
Main Methods:
- A comparative study design utilizing video-recorded standardized simulated patient encounters.
- Documentation time was meticulously recorded for three distinct scenarios across two EHR systems.
- Trainees at various levels (medical students, residents) participated in the study.
Main Results:
- No overall significant difference in documentation time was found between the two EHR systems.
- A significant difference in documentation time was observed based on trainee classification (p < .001).
- Second- and third-year trainees demonstrated significantly faster documentation on the Cerner system compared to fourth-year medical students and first-year trainees.
Conclusions:
- Physician documentation time in EHRs is influenced by the level of training and prior system experience.
- The Cerner EHR system showed a time advantage for more experienced trainees in this simulated ED setting.
- Further research is warranted to explore EHR design features that optimize documentation efficiency for all users.
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