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Methods of Documentation VII: EMR

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...

Methods of Documentation IV: Focus Charting

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Methods of Documentation III: PIE

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Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:

Methods of Documentation VI: Case Management Model

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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Methods of Documentation V: CBE

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Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...

Methods of Documentation II: POMR

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The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.

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Characterizing and Visualizing Display and Task Fragmentation in the Electronic Health Record: Mixed Methods Design.

Yalini Senathirajah¹, David R Kaufman², Kenrick D Cato³

¹Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.

JMIR Human Factors

|October 21, 2020

Summary

Analyzing electronic health record (EHR) user interfaces revealed that composable EHRs significantly reduce screen transitions compared to commercial versions. This optimization improves workflow efficiency by minimizing display fragmentation.

Keywords:

data visualization electronic health record electronic medical record information technology medical informatics user computer interface

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Area of Science:

Health Informatics
Human-Computer Interaction
Usability Engineering

Background:

Electronic health records (EHRs) present usability challenges due to complex data and workflows.
Display fragmentation, where data is scattered across screens, increases cognitive burden and complicates navigation.
Task and information fragmentation further exacerbate user difficulties in EHR systems.

Purpose of the Study:

To define and analyze sources of fragmentation within EHR user interfaces (UIs).
To explore theoretical, historical, and practical aspects of EHR fragmentation.
To employ microanalytic methods and visualizations for understanding fragmentation and identifying EHR optimization opportunities.

Main Methods:

Sunburst visualizations were used to map EHR navigation structures and calculate the Display Fragmentation Index.
Time belt visualizations quantified task fragmentation by analyzing sequences of subtasks.
These visualization techniques were applied to compare commercial and composable EHR interfaces.

Main Results:

The composable EHR interface demonstrated a significant reduction in screen transitions (43 to 14) compared to the commercial interface.
The number of clicks, including scrolling, remained comparable between the two interface types.
This indicates improved navigation efficiency in the composable EHR.

Conclusions:

The developed methods provide insights into UI requirements for complex health care tasks.
These techniques can guide the optimization of EHR workflows and inform future EHR redesign efforts.
Understanding and reducing fragmentation is key to enhancing EHR usability.