A Qualitative Analysis of EHR Clinical Document Synthesis by Clinicians

AMIA 2012 Annual Symposium

Oladimeji Farri ; MBBS 1 ; David S. Pieckiewicz ; PhD 1 ; Ahmed S. Rahman ; BS 1 Terrence J. Adam MD ; PhD 1 ; 2 ; Serguei V. Pakhomov ; PhD 1 ; 2 ; Genevieve B. Melton ; MD ; MA 1 ; 3 1

PID  :  129484

来源: CEUR

【 摘 要 】

Clinicians utilize electronic health record (EHR) systems during timeconstrained patient encounters where largeamounts of clinical text must be synthesized at the point of care. Qualitative methods may be an effective approachfor uncovering cognitive processes associated with the synthesis of clinical documents within EHR systems. Weutilized a thinkaloud protocol and content analysis with the goal of understanding cognitive processes and barriersinvolved as medical interns synthesized patient clinical documents in an EHR system to accomplish routine clinicaltasks. Overall, interns established correlations of significance and meaning between problem, symptom andtreatment concepts to inform hypotheses generation and clinical decisionmaking. Barriers identified withsynthesizing EHR documents include difficulty searching for patient data, poor readability, redundancy, andunfamiliar specialized terms. Our study can inform recommendations for future designs of EHR clinical document