“What’s the best way to document information concerning psychiatric patients? I just don’t know”—A qualitative study about recording psychiatric patients notes in the era of electronic health records

Abstract

This paper reports the results of a qualitative study regarding the main attitudes and concerns of Swiss psychiatrists related to the utility, usability and acceptability of EHR and how they address the pitfalls of sharing sensitive information with other parties. A total of 20 semi-structured interviews were carried out. Applied thematic analysis was used to identify themes with regard to participation. Three main themes were identified: 1) strengths of the use of EHR in the clinical context; 2) limitations of EHR; and 3) recommendations on preserving confidentiality in health records. The study shows variable practices of EHR use in psychiatric hospitals in Switzerland and a lack of standards on how to document sensitive information in EHR.

The Impact of Digital Hospitals on Patient and Clinician Experience: Systematic Review and Qualitative Evidence Synthesis

“…There was the potential to lose focus on the patient, undermine rapport [ 86 ], and communicate with the computer in lieu of direct bedside patient communication [ 81 ]. The effect of digital documentation on trust in the psychiatrist-patient relationship was noted, and required open communication between the psychiatrist and patient to promote transparency about what was documented [ 100 ].…”

“…Perceptions on patient preferences to protect the disclosure of medical information involved elements such as diagnoses [ 100 ], mental health–related stigma [ 100 ], and patient distrust of the EMR system or its users [ 86 ]. Reported strategies enlisted by health care professionals were to only include clinical documentation that was general in nature, avoid labeling (eg, “mood disorder” instead of “depression”) [ 100 ], prioritize based on clinical relevance [ 100 ], or limit types of information to critical information related to medication that is considered essential knowledge [ 86 ].…”

“…There is a pop up in the system which questions are you supposed to give that medication right now? [103] The safety benefits of sharing medical information [100] and applying regulatory frameworks to the workflow [100] were noted. Entering clinical data into structured mandatory fields and managerial-level review improved thoroughness and was considered to enhance patient safety [78].…”

“…Paper enabled total customization to fit with workflow conventions and was a "cognitive support" to supplement personal workflows to plan and prioritize in a flexible, convenient, comfortable, and trusted way [58]: The improved documentation captured by the EMR created a perceived privacy risk for the patient. Perceptions on patient preferences to protect the disclosure of medical information involved elements such as diagnoses [100], mental health-related stigma [100], and patient distrust of the EMR system or its users [86]. Reported strategies enlisted by health care professionals were to only include clinical documentation that was general in nature, avoid labeling (eg, "mood disorder" instead of "depression") [100], prioritize based on clinical relevance [100], or limit types of information to critical information related to medication that is considered essential knowledge [86].…”