Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians

Embí, Peter J.; Yackel, Thomas R.; Logan, Jeongok G.; Bowen, Judith L.; Cooney, Thomas G.; Gorman, Paul N.

doi:10.1197/jamia.m1525

Cited by 148 publications

(140 citation statements)

References 26 publications

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“…40,41 This may in part be driven by EHR templates designed for easy data extraction for billing and coding, but not for inclusion of a diagnostic or therapeutic rationale connecting the discharge information to the outpatient provider's task. Studies of the VA's EHR have suggested that the practice of copying and pasting notes also leads to both "benign" and "misleading" errors, as well as to a lack of updates regarding patient conditions, and to redundant information, 42 which may point to inherent limits of EHRs compared to paper records. 22 Awareness of the significance of discontinuities in care has been heightened with the recognition that medical error is the third leading cause of death in the United States.…”

Section: Discussionmentioning

confidence: 99%

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

Rattray

Sico

Cox

et al. 2017

The Joint Commission Journal on Quality and Patient Safety

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Background: Transitions of care from specialty and acute settings to primary care abound. Compared to the continuity in end-of-shift handoffs, care transitions involve provider communication between practices and facilities with their own cultures and bureaucracies. Using the transition from acute care to outpatient primary care for stroke/transient ischemic attack (TIA) patients as a case study, this qualitative research explored communication practices and institutional arrangements among clinical providers responsible for longitudinal management of hypertension.

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Section: Discussionmentioning

confidence: 99%

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

Rattray

Sico

Cox

et al. 2017

The Joint Commission Journal on Quality and Patient Safety

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show abstract

“…Computerized documentation is the direct entry of a physicians’ notes into the electronic medical record (EMR) through the intrahospital network, and offers improved legibility and real‐time accessibility 1. Such integrated EMR systems can ensure that a physician's documentation is easier to browse than a traditional paper record; thereby, providing reference for the next examination 2…”

Section: Introductionmentioning

confidence: 99%

Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study

Takechi

Dote

Kim

et al. 2017

Acute Medicine & Surgery

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AimWe hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital‐attending physicians’ decision‐making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D‐dimer result were reported by ED physicians in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital‐attending physicians.MethodsIn an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D‐dimer measurement (≥1.0 μg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected the decisions of attending physicians to order lower extremity venous ultrasonography examinations during hospitalization. The exposure variable was the quality of the ED physicians’ assessment of patients with positive D‐dimer results. The outcome was whether a lower extremity venous ultrasonography examination was ordered by the attending physician during hospitalization.ResultsWhen assessments were described by ED physicians for patients with positive D‐dimer results, the attending physicians frequently ordered lower extremity venous ultrasonography (odds ratio, 10.74; 95% confidence interval, 5.92–19.50), even if the assessments only contained “copied and pasted” laboratory data (odds ratio, 1.68; 95% confidence interval, 2.10–2.40).ConclusionsBetter documentation by ED physicians, regarding patients with positive D‐dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.

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“…P.J. Embi et al [38] lament that, these benefits are often coupled with unintended consequences in the actual work practices, such as increased documentation time incompatibility with clinical workflow more interruptions in medical work and system-introduced errors in patients care.…”

Section: Database Management System In the Field Of Medicinementioning

confidence: 99%

“…Embi et al [38] there are some causes of medical errors and one of these is due to different physicians treating the same patient. Not all or only a few physicians can access to all the patient's medical records.…”

Section: Database Management System In the Field Of Medicinementioning

confidence: 99%

An Emiprical Analysis on the Uses and Effects of Medical Database Management System by Medical Doctors in Tamil Nadu

Jayaseelan¹,

Pichandy²

2017

IJMS

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E-health system in India as well as in other countries is confronted with growing demand for medical treatment and services. The medical records must suitably have all of the medical history of the patients. Medical doctors should have proper records, since this can help doctors as well as patients in various situations. The present investigation attempts to unearth the usage and effects of Information and Communication Technology among medical doctors in the field of medicine to enhance their profession in Tamil Nadu, India. In this endeavor, the primary task of the researchers is to apply the appropriate technique to identify individuals, who will constitute the sample for the present study and also develop a reliable instrument to measure the perception of the respondents and the uses and effects of Information and Communication Technology in the field of medicine. The researcher is bestowed with the onerous task of identifying the right samples that are medical doctors and the right place where they work (government, private and own clinic) to collect reasonably representative data. This deals with the procedure adopted for developing the psychometric instrument (questionnaire), which has been used to elicit information on the uses and effects of information and communication technology by the medical doctors in the field of medicine. The results of the study reveal the major patterns of the usage of medical database management system. However, the stage also points out the grey areas, especially in the government sector, the need for proper implementation, diffusion and adoption of ICT.

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Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians

Cited by 148 publications

References 26 publications

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study

An Emiprical Analysis on the Uses and Effects of Medical Database Management System by Medical Doctors in Tamil Nadu

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