Authors
- Brandt, Kathleen RN, BSN
Article Content
Background:
Electronic medical records (EMRs) are intended to improve the accuracy and availability of data. This article reviewed current research articles as well as publications from respected journals on the quality of progress note documentation within the EMR.
Methods:
A systematic literature review was performed using research articles and applicable publications with the keywords electronic medical records, accuracy, quality, and usability using MeSH terms in PubMed, Medline, and CINAHL. Studies were eliminated from review if the EMR was not the sole source of documentation. Seventeen studies were included in this review.
Results:
Quality was defined as data that are accurate, complete, relevant, and accessible. Three studies demonstrated incomplete and inaccurate documentation occurring in the electronic records of various disciplines and settings due to free text or prompted entries.1-3 Five studies at Veterans Affairs (VA) facilities examined the copying and pasting of notes within the EMR.4-8 It was found that 9% of progress notes had a copied event with 10% to 31% resulting in clinically misleading risky information (type 5 and 6 errors), with physical or mental examinations being the most frequent category. Authors copied either their own examination note or that of others in 25% of the charts. The most frequent authors of the copied notes were physicians (50% of all authors), who had the most copying errors (89% with a mean of two errors per note), followed by nurses (21%, with 1% copying errors) and medical students (11%, with 5% copying errors). Six studies and two papers suggested that this behavior is a result of a mismatch between the technology and the work flow of the healthcare providers.2,9-15 Finally, two studies examined the effect of changing user interface design to increase users' satisfaction and decrease input errors.16,17
Conclusions:
A potential for misinformation and lack of easy access to and retrieval of information is a major cause for concern. More attention needs to be focused on user interface design and customization to the healthcare workers' work flow environment, which would improve user's satisfaction and trust of the information accuracy as well as decrease cognitive overload. Given the stellar history of the EMR within the VA, others may gain insight for this potential misinformation and redundancy of information as their documentation system matures. Furthermore, this review suggests the need for extended postimplementation evaluations.
Acknowledgment:
Special thanks to Eun-Shim Nahm, PhD, MS, RN.
References:
1. Driscoll WD, Columbia MA, Peterfreund RA. An observational study of anesthesia record completeness using an anesthesia information management system. Anesth Comput. 2007;104:1454-1461. [Context Link]
2. Kossman SP. Perceptions of impact of electronic health records on nurses' work. Stud Health Technol Inform. 2006;122:337-341. [Context Link]
3. Soto CM, Kleinman KP, Simon SR. Quality and correlates of medical record documentation in the ambulatory care setting. Biomed Cent Health Serv Res. 2002:2(2). [Context Link]
4. Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impact of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physician. J Am Med Inform Assoc. 2004;11:300-309. [Context Link]
5. Hammond KW, Helbig ST, Benson CC, Braithwaite-Sketoe BM. Are electronic medical records trustworthy? Am Med Inform Assoc Symp Proc. 2003:269-273. [Context Link]
6. Thielke S, Hammond K, Helbig S. Coping and pasting of examinations within the electronic medical record. Int J Med Inform. 2007;76S:S122-S128. [Context Link]
7. Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes: an evaluation of input errors. Methods Inf Med. 2003;42:61-67. [Context Link]
8. Weir CR, Nebeker JJ, Hicken BL, Campo R, Drews F, Lebar B. A cognitive task analysis of information management strategies in a computerized provider order entry environment. J Am Med Inform Assoc. 2007;14(1):65-75. [Context Link]
9. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11:104-112. [Context Link]
10. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547-556. [Context Link]
11. Johnson KB, Ravich WJ, Cowan JA. Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey. Int J Med Inform. 2004;73:665-674. [Context Link]
12. Patterson ES, Cook RL, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc. 2002;9:540-553. [Context Link]
13. Rosenbloom ST, Crow AD, Blackford JU, Johnson KB. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform. 2007;40:106-113. [Context Link]
14. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care. J Am Med Inform. 2007;14:542-549. [Context Link]
15. Kushniruk AW, Patel VL. Cognitive and usability engineering methods for the evaluation of clinical information systems. J Biomed Inform. 2004;37:56-76. [Context Link]
16. Rose AF, Schnipper JL, Park ER, Poon EG, Li Q, Middleton B. Using qualitative studies to improve the usability of an EMR. J Biomed Inform. 2005;38:51-60. [Context Link]
17. Rosenbloom ST, Grande J, Geissbuhler A, Miller RA. Experience in implementing inpatient clinical note capture via a provider order entry system. J Am Med Inform Assoc. 2004;11:310-316. [Context Link]