The transition to electronic documentation on a teaching hospital medical service

Abstract

The transition to electronic medical records (EMRs) often includes the transition from paper to electronic documentation, a topic less well described in the literature than other aspects of EMR adoption. As part of a broader EMR project, we have participated in the transition to electronic notes on the Medicine service of a teaching hospital affiliated with the University of Washington. During a one year period beginning in February 2005 we adopted the use of semi-structured documentation templates permitting both encoded and narrative text components for admission, progress, and procedure notes, and for some discharge summaries. Currently over 1400 notes are entered each week. Fifty eight percent are entered by residents, 20% by attending physicians, and the remainder by other trainees and staff. The period of greatest change from paper to electronic notes occurred (by design) during the late spring and summer. Leadership, application functionality, speed, note writing time requirements, data availability, training needs, and other factors influenced adoption of this important part of our EMR.

Figure 1

The number of Powernotes signed each week between March 2005 and February 2006.

Figure 2. Example of Powernote

As described in text, note is entered by selecting from coded choices, entering narrative text in a ‘WHAT’ box, or importing from patient results.