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Keywords

Clinical documentation, Clinical informatics, Colposcopy, Electronic health record, Structured note

 

Authors

  1. GOLDMAN, JOANNE MSc
  2. ABRAMOVICH, ILONA ALEX MA
  3. SADOVY, BOHDAN IMG MHSc
  4. MURPHY, K. JOAN MD, FRCSC
  5. RICE, KATHLEEN MA
  6. REEVES, SCOTT PhD

Abstract

Hospital-wide electronic medical records can be limited in addressing clinical department needs. A study was undertaken to examine the development and implementation of an electronic informaton system in a colposcopy unit in a large teaching hospital in Canada. A case study design was used, and 24 semistructured interviews were conducted with nurses and physicians working in the colposcopy clinic and individuals from the information technology team. Interviews occurred in two phases-directly after implementation and again 9 months later. Computerized audit data were gathered to examine usage patterns. The results provide insight into the processes and challenges of defining and capturing information for both clinical and research purposes and creating a standardized referral note. The findings demonstrated some initial uncertainty around roles and responsibilities concerning the electronic system and its integration into clinical routines. After a period of 12 months, and further refinement, it was found that the system was accessible and user-friendly, although some concerns raised during the developmental stage persisted. Audit data revealed that 9 months after its introduction, nurses' adoption of the system rate reached 89%, and physicians, 96%. This study has demonstrated that practitioners in a colposcopy clinic successfully collaborated with information technology specialists and each other to develop and implement a clinical departmental information system. While certain challenges were encountered, nurses and physicians have bought into the system, recognize its potential for research and patient care, and are therefore committed to figuring out how to adapt to the changes in communication both within the clinic and with referring physicians.