Clinicians’ reasoning as reflected in electronic clinical note-entry and reading/retrieval: a systematic review and qualitative synthesis

Abstract

Objective To describe the literature exploring the use of electronic health record (EHR) systems to support creation and use of clinical documentation to guide future research. Materials and Methods We searched databases including MEDLINE, Scopus, and CINAHL from inception to April 20, 2018, for studies applying qualitative or mixed-methods examining EHR use to support creation and use of clinical documentation. A qualitative synthesis of included studies was undertaken. Results Twenty-three studies met the inclusion criteria and were reviewed in detail. We briefly reviewed 9 studies that did not meet the inclusion criteria but provided recommendations for EHR design. We identified 4 key themes: purposes of electronic clinical notes, clinicians’ reasoning for note-entry and reading/retrieval, clinicians’ strategies for note-entry, and clinicians’ strategies for note-retrieval/reading. Five studies investigated note purposes and found that although patient care is the primary note purpose, non-clinical purposes have become more common. Clinicians’ reasoning studies (n = 3) explored clinicians’ judgement about what to document and represented clinicians’ thought process in cognitive pathways. Note-entry studies (n = 6) revealed that what clinicians document is affected by EHR interfaces. Lastly, note-retrieval studies (n = 12) found that “assessment and plan” is the most read note section and what clinicians read is affected by external stimuli, care/information goals, and what they know about the patient. Conclusion Despite the widespread adoption of EHRs, their use to support note-entry and reading/retrieval is still understudied. Further research is needed to investigate approaches to capture and represent clinicians’ reasoning and improve note-entry and retrieval/reading.

Copy-and-Paste in Medical Student Notes: Extent, Temporal Trends, and Relationship to Scholastic Performance

“…This SPI may not be representative of a given student's note-writing tendencies, although the paired SPI analysis mitigates this shortcoming to some extent. The analysis emphasized the assessment/ plan section for two main reasons: (1) it is the first section of a note to be read and the section that providers spend the most time reading 18 ; and (2) it was thought that this part of the note would be most reflective of idea synthesis and integration. Students may have displayed these cognitive attributes elsewhere in their notes, which would not have been reflected in our results.…”

Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era

“…However, CSR solutions may be compromised by the fact that clinicians may make conscious decisions about what information to communicate to patients and to document in the EHR [57]. Therefore, there are opportunities for research exploring what information clinicians document (or not) in the EHR and what information they do not communicate verbally to the patient but document in their clinical notes [58]; such findings will inform development of CSR and other data-entry solutions capable of handling such situations. Regarding data retrieval, EHR content retrieved by physicians is influenced by their tasks or information goals [59,60]; however, such stimuli are not captured by current EHRs.…”

“…Regarding data retrieval, EHR content retrieved by physicians is influenced by their tasks or information goals [59,60]; however, such stimuli are not captured by current EHRs. Future research should investigate how EHRs can support data retrieval with intelligent stimulus- or goal-oriented functionality that allows a holistic view of the patient and flexible navigation across the record [58] to hopefully decrease the documentation burden and its contribution to the next UC: data obfuscation.…”

“…Context-rich data could be used to facilitate note creation, to create automatic notes ready for review, and to increase the accuracy of CDS, potentially mitigating the already infamous alert fatigue [37]. However, 2 major challenges remain: (1) A formal representation of the semantic relationships between clinical concepts (eg, symptoms, findings, problems, diagnoses, and treatments) does not exist and (2) Effective methods for capturing and representing clinicians’ reasoning need to be developed [58]. EHR vendors have avoided this path to avert coliability for medical errors when eventual system failures lead to misleading recommendations [77,78].…”

Accelerating the De-Personalization of Medicine: The Ethical Toxicities of COVID-19

“…In this regard it is noteworthy that, increasingly, the first encounter with a newly admitted patient is electronic—an encounter with the ‘iPatient’—the virtual construct of the patient in the computer (Verghese 2008 ), reflecting a process of “digitised embodiment” (Lupton 2014 ). Virtual patient rounding (Verghese 2008 ), associated minimalist physical interactions (Verghese et al 2015 ), heavy reliance on EMR data which may not “capture and represent what clinicians are thinking about the patients and their problems” (Colicchio and Cimino 2018 , 182), and “chart biopsy” (Hilligoss and Zheng 2012 ; Kendall et al 2013 ) are new forms of behaviour facilitated by heavy reliance on the EMR.…”