SummaryElectronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children's Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.
BackgroundElectronic Medical Records (EMRs) have been widely implemented in the past decade [1,2]. A primary emphasis of EMR deployments has been on improving patient safety by employing computerized physician order entry (CPOE) and clinical decision support systems (CDSS). While there have been many reports on the benefits of CPOE and CDSS, [3,4] there have been fewer reports on the impact of electronic physician documentation. However, barriers to adoption such as disruption of the physician's workflow and perceived increased time required to document have been noted [1,5]. Additionally, unintended consequences of conversion to electronic notes have been documented [6,7]. This report describes the implementation of inpatient physician documentation at an academic pediatric and obstetric hospital and how we addressed these challenges. This work was conducted at Lucile Packard Children's Hospital (LPCH) at Stanford University Medical Center (SUMC). LPCH serves as the major teaching hospital for pediatric and obstetric care for SUMC. In 2010, LPCH had 303 beds (of which 118 are intensive care beds and 52 are obstetrics beds), and 12,898 discharges and 4,575 births. LPCH has 1,051 attending physicians on the medical staff. At SUMC there are approximately 1,065 residents and fellows (81 pediatric residents, 84 pediatrics fellows, and 25 obstetric residents).In 2007 a clinical transformation program was implemented at LPCH, which included CPOE and electronic documentation by nurses and support personnel [4]. Electronic physician notes were not implemented at that time. However, without physician notes available in the EMR, the medical record was fragmented as these notes were not readily available to all of the caregivers. Workflow was also fragmented as physicians entered orders and reviewed nursing notes electronically, but still dictated or handwrote their own notes. Therefore, in 2010 an electronic inpatient clinical documentation project was undertaken.
Case ReportThe implementation team consisted of two analysts, a physician lead, a clinical informatics fellow, a programmer, and a project manager. The project was overseen by a steering committee consisting of the Chief...
