A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians

Abstract

Objective: The objective of this study is to understand physicians' usage of inpatient notes by (i) ascertaining different clinical note-entry and reading/retrieval styles in two different and widely used Electronic Health Record (EHR) systems, (ii) extrapolating potential factors leading to adoption of various note-entry and reading/retrieval styles and (iii) determining the amount of time to task associated with documenting different types of clinical notes.

Methods: In order to answer "what" and "why" questions on physicians' adoption of certain-note-entry and reading/retrieval styles, an ethnographic study entailing Internal Medicine residents, with a mixed data analysis approach was performed. Participants were observed interacting with two different EHR systems in inpatient settings. Data was collected around the use and creation of History and Physical (H&P) notes, progress notes and discharge summaries.

Results: The highest variability in template styles was observed with progress notes and the least variability was within discharge summaries, while note-writing styles were most consistent for H&P notes. The first sections to be read in a H&P and progress note were the Chief Complaint and Assessment & Plan sections, respectively. The greatest note retrieval variability, with respect to the order of how note sections were reviewed, was observed with H&P and progress notes. Physician preference for adopting a certain reading/retrieval order appeared to be a function of what best fits their workflow while fulfilling the stimulus demands. The time spent entering H&P, discharge summaries and progress notes were similar in both EHRs.

Conclusion: This research study unveils existing variability in clinical documentation processes and provides us with important information that could help in designing a next generation EHR Graphical User Interface (GUI) that is more congruent with physicians' mental models, task performance needs, and workflow requirements.

Keywords: Clinical documentation; Electronic health records systems (EHR); Graphical User Interface (GUI); Human-Computer Interaction (HCI); Qualitative analysis; Usability.

Figure 1. Typical call and day schedule of residents at UMMC-Hospital (H1) and VAHCS-Hospital (H2)

The figure shows approximate times, other than for morning report and noon conference which have set times. Nightfloat residents or a resident on sub-specialty month do not follow the above schedule

Figure 2. Note template styles for H&P, progress note and discharge summary as adopted by physicians

* H1:UMMC-University of Minnesota Medical Center; H2:VAHCS-Veterans Affairs Health Care System; Sn: Number of participants; T=Total participants; Nn: Number of notes; CC: Chief Complaint; HPI: History of Present Illness; PMH: Past Medical History; PSH: Past Surgical History; ROS: Review of Symptoms; PE; Physical Exam; SH: Social History; FM; Family History; A/P: Assessment & Plan; S: Subjective; DD: Discharge Diagnoses; HCP: Hospital Course by Problem

Figure 3. Note-writing styles for H&P, progress note and discharge summary as adopted by physicians

*H1-UMMC: University of Minnesota Medical Center; H2-VAHCS: Veterans Affairs Health Care System; Sn: Number of participants; T=Total participants; Nn: Number of notes; CC: Chief Complaint; HPI: History of Present Illness; PMH: Past Medical History; PSH: Past Surgical History; ROS: Review of Symptoms; PE: Physical Exam; SH: Social History; FM; Family History; A/P: Assessment & Plan; S: Subjective; DD: Discharge Diagnoses; HCP: Hospital Course by Problem. Dotted lines represent various patterns adopted

Figure 4. Note retrieval/reading styles for H&P, progress note and discharge summary as adopted by physicians

*H1-UMMC: University of Minnesota Medical Center; H2-VAHCS: Veterans Affairs Health Care System; Sn: Number of participants; T=Total participants; In: Number of Instances; CC: Chief Complaint; HPI: History of Present Illness; PMH: Past Medical History; PSH: Past Surgical History; ROS: Review of Symptoms; PE; Physical Exam; SH: Social History; FM; Family History; A/P: Assessment & Plan; S: Subjective; DD: Discharge Diagnoses; HCP: Hospital Course by Problem

Figure 5. Summary of preferred note-entry and retrieval styles as adopted by physicians

*CC: Chief Complaint; HPI: History of Present Illness, PE: Physical Exam; PMH: Past Medical History; SH: Social History; FH: Family History; PSH: Past Surgical History; ROS: Review of Symptoms; A/P: Assessment & Plan; S: Subjective: O: Objective; A/P: Assessment & Plan; DD: Discharge Diagnoses; HCP: Hospital Course by Problem

Figure. 6

Observed time in minutes for entering different types of notes in two EHRs subjective data