Transition from paper to electronic inpatient physician notes

Abstract

UW Medicine teaching hospitals have seen a move from paper to electronic physician inpatient notes, after improving the availability of workstations, and wireless laptops and the technical infrastructure supporting the electronic medical record (EMR). The primary driver for the transition was to unify the medical record for all disciplines in one location. The main barrier faced was the time required to enter notes, which was addressed with data-rich templates tailored to rounding workflow, simplified login and other measures. After a 2-year transition, nearly all physician notes for hospitalized patients are now entered electronically, approximately 1500 physician notes per day. Remaining challenges include time for note entry, and the perception that notes may be more difficult to understand and to find within the EMR. In general, the transition from paper to electronic notes has been regarded as valuable to patient care and hospital operations.

Figure 1

Example of partially written note using Clinical Note Editor (A) and PowerNote (B) demonstrating differences in the end user experience. Clinical Note Editor has a familiar text editor appearance. PowerNote has the ability to run macros, insert needed paragraph headings, and other features. Both permit automatic inclusion of patient-specific data such as current medication lists. The patient data in this figure are fictitious.