Clinical Documentation as End-User Programming.

Area of Science:

• Health Informatics
• Ophthalmology

Background:

• Electronic health records (EHRs) offer advanced documentation tools.
• Custom note templates are increasingly common in EHRs.
• Limited understanding exists on how clinicians utilize these documentation aids.

Purpose of the Study:

• To investigate the utilization of content-importing phrases by ophthalmologists and staff.
• To analyze how these customizable note templates are created and employed in clinical documentation.

Main Methods:

• A case study approach was employed.
• Data were collected over two years from 48 ophthalmologists and their staff.
• The creation and use of content-importing phrases for documenting office visits were examined.

Main Results:

• Content-importing phrases were used in 95% of documented patient visits.
• The majority of imported content consisted of structured data via data-links, rather than static text.
• Physicians predominantly used self-created phrases, whereas staff utilized phrases made by others.

Conclusions:

• Clinical documentation can be conceptualized as end-user programming.
• Findings can inform the design of EHRs and documentation systems that integrate data and narrative.
• The study highlights user-specific patterns in leveraging customizable EHR templates.