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Related Concept Videos

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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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Exploring Physicians' Dual Perspectives on the Transition From Free Text to Structured and Standardized Documentation

Olga Golburean1, Rune Pedersen2, Line Melby3

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Summary

Physicians gradually adopted new electronic health record (EHR) systems, but free text remained preferred over structured data. Implementing standardized templates and tailored training can improve clinical documentation and data exchange.

Keywords:
EHRdocumentationdocumentation practiceelectronic health recordinteroperabilitysecondary use of datastandardized documentationstructured documentation

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Area of Science:

  • Health Informatics
  • Medical Documentation
  • Human-Computer Interaction in Healthcare

Background:

  • Effective clinical documentation is vital for care coordination and delivery.
  • Despite widespread electronic health record (EHR) adoption, many physicians still use paper-based documentation methods.
  • New documentation approaches are needed to optimize EHR benefits for point-of-care access and data exchange.

Purpose of the Study:

  • To evaluate the impact of transitioning to a cross-institutional EHR system on physicians' documentation practices.
  • To understand factors influencing physicians' preference for free text versus structured and standardized documentation.

Main Methods:

  • A qualitative study involving participant observation and semistructured interviews with physicians.
  • Conducted at a university hospital in Norway from September 2023 to January 2024.
  • Data analyzed using reflexive thematic analysis.

Main Results:

  • Physicians initially faced challenges with the new EHR system's complexity but gradually adopted new processes through experience and peer collaboration.
  • While structured documentation increased, free text remained preferred, leading to some distrust in standardized data.
  • Physicians found templates beneficial for routine procedures, though often created their own with free-text entries.

Conclusions:

  • Physicians' adoption of new documentation processes is influenced by social and technological factors like experience, perceived benefits, and system usability.
  • Standardized or semi-standardized templates and customized training programs are recommended to improve documentation consistency and facilitate EHR transitions.
  • Addressing physicians' preferences for free text within templates is crucial for enhancing data recording and adherence to guidelines.