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Despite widespread adoption and maturity, paper persistence endures in many Electronic Health Record (EHR) systems, particularly for complex workflows involving multiple steps from different stakeholders separated in time. In our health system, Latent Tuberculosis Infection (LTBI) testing was one such workflow where a Tuberculin Skin Test (TST) must be administered and then correctly read 48-72 hours later and documented. This paper discusses a low-resource workflow analysis and clinical decision support approach to replace a paper workflow and garner the benefits of the EHR for clearer documentation and retrieval of LTBI results. Our approach resulted in a significant increase in completed TST documentation, 57% (24/42) to 95% (18/19), P < 0.003. Human-centered design practices such as work system analysis and formative usability testing are feasible with limited resources and improve the likelihood of success of electronic workflows by designing solutions that fit existing clinical workflows and automating processes wherever possible.

Objective: To examine changes in registered nurse (RN) perceptions of electronic documentation over a 4-year period., Background: The investigators previously reported differences in RN perceptions prior to and 1 year after adoption of a comprehensive electronic health record (EHR)., Methods: Investigators repeated the study 4 years after adoption, using the Nurses' Perceptions of Electronic Documentation tool and interviews with a subset of RNs., Results: Nurses scored higher on ease of use domain and lower on concern about the EHR domain and showed no difference on the impacts of the EHR domain. Interviews revealed that 4 years later, some aspects of documentation were easier; the tool was comprehensive, but not without risk, and nurses remained ambivalent about the EHR., Conclusions: Use of EHR technology impacts nursing work. It is important to understand how nurses' perceptions change over time. This study gives nursing leaders insight into adoption and acceptance of an EHR.

Vision problems can lead to negative developmental outcomes. Children with Williams syndrome and Down syndrome are at higher risk of vision problems, and these are less likely to be detected due to diagnostic overshadowing and difficulty accessing eye-care. Education, Health and Care (EHC) plans are statutory documents, introduced by the Children and Families Act 2014 in England, with the intention of integrating provision across these domains. Vision issues should be reported in these plans, and recommendations made about appropriate adjustments for them. We analysed the EHC plans from 53 children with Down or Williams syndrome. Our results showed significant underreporting, especially for children with Williams syndrome, and little explanation of what adjustments should be made. We also report pockets of good practice.

While subjective judgment is recognized by the health professions education literature as important to assessment, it remains difficult to carve out a formally recognized role in assessment practices for personal experiences, gestalts, and gut feelings. Assessment tends to rely on documentary artefacts-like the forms, standards, and policies brought in under competency-based medical education, for example-to support accountability and fairness. But judgment is often tacit in nature and can be more challenging to surface in explicit (and particularly written) form. What is needed is a nuanced approach to the incorporation of judgment in assessment such that it is neither in danger of being suppressed by an overly rigorous insistence on documentation nor uncritically sanctioned by the defense that it resides in a black box and that we must simply trust the expertise of assessors. The concept of entrustment represents an attempt to effect such a balance within current competency frameworks by surfacing judgments about the degree of supervision learners need to care safely for patients. While there is relatively little published data about its implementation as yet, one readily manifest variation in the uptake of entrustment relates to the distinction between ad hoc and summative forms. The ways in which these forms are languaged, together with their intended purposes and guidelines for their use, point to directions for more focused empirical inquiry that can inform current and future uptake of entrustment in competency-based medical education and the responsible and meaningful inclusion of judgment in assessment more generally.

Objective: The study sought to understand the potential roles of a future artificial intelligence (AI) documentation assistant in primary care consultations and to identify implications for doctors, patients, healthcare system, and technology design from the perspective of general practitioners., Materials and Methods: Co-design workshops with general practitioners were conducted. The workshops focused on (1) understanding the current consultation context and identifying existing problems, (2) ideating future solutions to these problems, and (3) discussing future roles for AI in primary care. The workshop activities included affinity diagramming, brainwriting, and video prototyping methods. The workshops were audio-recorded and transcribed verbatim. Inductive thematic analysis of the transcripts of conversations was performed., Results: Two researchers facilitated 3 co-design workshops with 16 general practitioners. Three main themes emerged: professional autonomy, human-AI collaboration, and new models of care. Major implications identified within these themes included (1) concerns with medico-legal aspects arising from constant recording and accessibility of full consultation records, (2) future consultations taking place out of the exam rooms in a distributed system involving empowered patients, (3) human conversation and empathy remaining the core tasks of doctors in any future AI-enabled consultations, and (4) questioning the current focus of AI initiatives on improved efficiency as opposed to patient care., Conclusions: AI documentation assistants will likely to be integral to the future primary care consultations. However, these technologies will still need to be supervised by a human until strong evidence for reliable autonomous performance is available. Therefore, different human-AI collaboration models will need to be designed and evaluated to ensure patient safety, quality of care, doctor safety, and doctor autonomy., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Objective: The aim of this study was to quantify the impact of electronic health record (EHR) workstation single sign-on (SSO) for nurses., Background: SSO was implemented in 19 hospitals for expedited EHR access., Methods: Login durations before and after SSO implementation were compared, and the financial value of nursing time liberated from keyboard was estimated. Stratified analyses show time liberated and financial value by staffing level and system size., Results: First-of-shift login was reduced by 5.3 seconds (15.3%) and reconnect duration was reduced by 20.4 seconds (69.9%). SSO liberated 27,962.4 hours of nursing time from keyboard login per year across 19 facilities, and 1,471.7 hours/year/facility, valued at $52,112/facility and $990,128 for 19 hospitals. Time value ranges from $201,835 per year for a 5-hospital system with 300 nurses per facility to $672,790 per year for a 10-facility system with 500 nurses per hospital., Conclusions: Nurses gained substantial time liberated from EHR keyboard by SSO for patient care, having significant financial value for the organization.

Context: Previous research on athletic trainers' (ATs) documentation practices in the secondary school setting has focused on users of 1 electronic medical record (EMR) platform. These studies have identified that ATs use multiple platforms for documentation, including paper, even when an EMR is available., Objective: To examine the documentation practices of ATs who use various forms of patient care documentation, including paper, EMRs, or both., Design: Qualitative study., Setting: Individual telephone interviews., Patients or Other Participants: Twenty ATs participated in this study: 12 women and 8 men who averaged 38 ± 14 years of age, 15 ± 13 years of clinical experience, and 11 ± 11 years of employment at their current secondary school., Data Collection and Analysis: Semistructured telephone interviews were conducted to gain insight into ATs' documentation practices. Three researchers and 2 auditors inductively coded the transcripts using a consensual qualitative research process that consisted of 4 rounds of consensus coding and determination of data saturation. Trustworthiness was addressed with member checking, multiple-analyst triangulation, and peer review., Results: The ATs' documentation practices were largely influenced by technology, organized in 3 themes. Participants' current documentation strategies included the use of both paper and EMRs, as they found different benefits to using each platform. Oftentimes documentation practices were shaped by technological challenges, including unreliable networks, software design problems, and the lack of a streamlined approach. Lastly, participants identified future strategies for improving documentation, including the need for better EMR options and streamlining their individual documentation behaviors., Conclusions: Many ATs wanted to incorporate EMRs in their clinical practice but faced challenges when attempting to do so. In turn, clinicians often duplicated documentation or used 2 platforms. Athletic trainers should communicate with administrators to select an EMR that fits their documentation needs and seek resources, such as network access and educational opportunities, to learn how to use EMRs., (© by the National Athletic Trainers' Association, Inc.)

Background: Sexual assault is a common and distressing occurrence. The medical needs of individuals presenting in the immediate aftermath of an assault may be obvious: addressing injuries and distress and providing the option of a forensic medical exam. However, the initial assessment and response to a disclosure of sexual assault is an important opportunity to address medical, safety and psychosocial concerns., Objective: The aim of this article is to discuss the practitioner's response to disclosures of recent sexual assault and the consequent legal, forensic and medical options. In particular, emergency contraception, sexually transmissible infections and management of injuries may be the patient's predominant concerns. Legal concerns, particularly relating to privacy and documentation, are also important in these cases., Discussion: Following a disclosure of recent sexual assault, a general practitioner may be juggling many concerns, both medical and legal. This article addresses some of these concerns and considers a medical response to a distressing situation in a way that minimises further trauma to the patient and the practitioner.

Introduction: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the mid- and low-acuity zones of an academic emergency department (ED) with and without medical scribes., Methods: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition., Results: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI], -17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI, -6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted., Conclusion: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation.

Introduction: Prompt and effective combat casualty care is essential for decreasing morbidity and mortality during military operations. Similarly, accurate documentation of injuries and treatments enables quality care, both in the immediate postinjury phase and the longer-term recovery. This article describes efforts to prototype a Military Medic Smartphone (MMS) for use by combat medics and other health care providers who work in austere environments., Materials and Methods: The MMS design builds on previous electronic health record systems and is based on observations of medic workflows. It provides several functions including a compact yet efficient physiologic monitor, a communications device for telemedicine, a portable reference library, and a recorder of casualty care data from the point of injury rearward to advanced echelons of care. Apps and devices communicate using an open architecture to support different sensors and future expansions., Results: The prototype MMS was field tested during live exercises to generate qualitative feedback from potential users, which provided significant guidance for future enhancements., Conclusions: The widespread deployment of this type of device will enable more effective health care, limit the impact of battlefield injuries, and save lives., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: According to the 2015 National Academy of Medicine report, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) "is a serious, chronic, complex, and systemic disease that frequently and dramatically limits the activities of affected patients." ME/CFS affects between 1 and 2.5 million Americans, leaving as many as 75% unable to work due to physical, cognitive and functional impairment. Unfortunately, many doctors and lawyers lack the knowledge of how to properly document an ME/CFS disability claim, leaving patients unable to access disability benefits., Objective: The goal of this article is to summarize the approaches used by experienced clinicians and lawyers in successful ME/CFS disability claims., Methods: The authors reviewed the types of US disability insurance programs and the evidence commonly required by these programs to demonstrate ME/CFS disability., Results: This article summarizes the range of methods used in successful US disability claims, which include documentation of the functional impact of post-exertional malaise and the use of methods that provide objective evidence of impairment., Conclusions: Medical providers and lawyers can use these tested methods to obtain disability benefits for people with ME/CFS. Physical therapists, occupational therapists, and other specialists play an important role in providing objective evidence for ME/CFS disability claims.

Background: Clinical observations have indicated that hours of upright activity (HUA) reported by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patients correlated with orthostatic symptoms and impaired physical function. This study examined the relationship between HUA and orthostatic intolerance (OI)., Methods: Twenty-five female ME/CFS subjects and 25 age and race matched female healthy controls (HCs) were enrolled. Subjects reported HUA (defined as hours per day spent with feet on the floor) and completed questionnaires to assess the impact of OI on daily activities and symptoms. ME/CFS patients were categorized into those with <5 HUA and ≥5 HUA and analyzed by employment status. Data analysis used one-way ANOVA., Results: ME/CFS patients had fewer HUA, worse symptoms and greater interference with daily activities due to OI than HCs. The <5 HUA ME/CFS subjects had more severe OI related symptoms than ≥5 HUA ME/CFS subjects even though OI interfered with daily activities similarly. Only 33% of ME/CFS subjects were employed and all were ≥5 HUA ME/CFS subjects with an average HUA of 8., Conclusions: ME/CFS subjects experienced more frequent and severe OI symptoms, higher interference with daily activities, and reduced ability to work than HCs. Reported HUA and assessment of OI using standardized instruments may be useful clinical tools for physicians in the diagnosis, treatment and management of ME/CFS patients.

An operation note is a medicolegal document. The Royal College of Surgeons (RCS) of England's Good Surgical Practice 2014 (GSP) sets out 19 points an operation note should include. This study aimed to assess if the introduction of an electronic patient record (EPR) improved the quality of general surgical operation notes. An annonymised retrospective case note review of general surgical operation notes was undertaken over five separate time periods. The first cycle consisted of periods 1 (prior to EPR implementation), 2 (1 week after EPR) and 3 (4 weeks after EPR). Period 4 was a reaudit 2 weeks after the initial results were presented at the local governance meeting. The cycle was then closed with period 5; 1 year after EPR implementation. A comparison was across all 5 time periods for compliance with the RCS guidelines and with subanalysis of the individual categories. 250 operation notes were reviewed during five time periods. Compliance improved by almost 19% (p=0.0003) between periods 1 and 5. Eleven of the 19 points (57.9%) over the audit period achieved 100% compliance post-EPR compared to 0% prior. Poor compliance were noted in the categories of antibiotic use, venous thromboembolism prophylaxis and estimated blood loss (noting that these are often documented in the anaesthetic record and/or WHO checklist). EPRs do not guarantee compliance with GSP. We propose that GSP standards need to be updated to reflect the modernisation of medical records and a team-based approach with multimodality input sources would achieve better patient records and patient care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.

Use of standardized terminology has been essential for clear, concise, and accurate documentation of client assessments, care plans, and outcomes. The purpose of this study was to create standardized language goals for a case management system that used the Omaha System. A group of nursing informaticists analyzed, refined, and developed revised goals evaluated using medical vocabulary properties. A set of unique goals aligned with the Omaha System was developed with specifically designed characteristics and functionality that allowed individualization and evaluation of goal attainment. Goal statements and ratings were standardized and written to reflect goals a client could attain. The Omaha System goals served as a template for nurse case managers to use in telephonic support with clients and future development of new goals and allowed the organization the ability to generate quality metrics.

Detailed clinical documentation is required in the patient-facing specialty of radiation oncology. The burden of clinical documentation has increased significantly with the introduction of electronic health records and participation in payer-mandated quality initiatives. Artificial intelligence (AI) has the potential to reduce the burden of data entry associated with clinical documentation, provide clinical decision support, improve quality and value, and integrate patient data from multiple sources. The authors discuss key elements of an AI-enhanced clinic and review some emerging technologies in the industry. Challenges regarding data privacy, regulation, and medicolegal liabilities must be addressed for such AI technologies to be successful., (Copyright © 2019 American College of Radiology. All rights reserved.)

Introduction: The objective of the study was to identify where epilepsy or seizures may be the underlying cause of death but not identified by the death certification process in the Australian coronial system and to better characterize such deaths., Methods: Australian National Coronial Information System (NCIS) closed cases for the Australian Capital Territory (ACT) (population average 348,000) over 13 years were searched using cause of death, and a text search of police and autopsy reports, to identify all deaths where epilepsy or seizures were mentioned. Deaths where the underlying cause of death was not seizures or epilepsy were excluded (including suicide). The remaining cases (75) were categorized by the circumstances of death. Suspected sudden unexpected death in epilepsy (SUDEP) cases were further classified using the unified definition of SUDEP of Nashef and colleagues (2012)., Results: Of the final 75 cases, only 44 were found by the cause of death search. Key word document searches found another 31. Cases were classified as Definite SUDEP (37), Definite SUDEP Plus (10), Probable SUDEP (1), Possible SUDEP (3), Near SUDEP (4), Near SUDEP Plus (1), Asphyxia (3), Treatment-related (1), Head injury (2), Drowning (2), motor vehicle accident (MVA) (1), deaths related to a single convulsive seizure (6), and status epilepticus (SE) (4). Cases were 80% male., Conclusions: Epilepsy and seizure-related deaths are underreported in the Australian Coronial system. Enhanced documentation of the causal chain of events leading to deaths would increase recognition. Using the unified SUDEP definition would expand SUDEP identification., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The purpose of the nursing practicum course is to enable students to integrate cognitive, psychomotor, and affective skills into professional competencies prior to clinical work. With advances in information technology, e-portfolio focusing on individualized learning, reflection, and self-management has received positive consideration. The nursing profession has since adopted it as part of nursing education., Purpose: This study explored the needs and perceptions of students in a baccalaureate nursing program regarding the use of e-portfolio in the final semester practicum course., Method: This study used semi-structured focus group interviews and applied the principles of content analysis to interview content., Results: Four key research themes were revealed: (1) anticipated functions achieved, (2) ease of uploading data and showcasing learning results (3) functionality extensions to enhance mobile learning, and (4) policy guidelines for mandatory use and plagiarism prevention., Conclusion: E-portfolio assists in integrating knowledge, practical skills, and achievement recognition into the learning process. The use of e-portfolio with upgrades can enable learning of clinical competencies by students in preparation for clinical nursing practice., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The Syria crisis has forced more than 4 million people to leave their homeland. As a result, in 2016, an overwhelming number of refugees reached Germany. In response to this, it was of utmost importance to set up refugee camps and to provide humanitarian aid, but a health surveillance system was also implemented in order to obtain rapid information about emerging diseases., Objective: The present study describes the effects of using digital paper and pen (DPP) technology on the speed, sequence, and behavior of epidemiological documentation in a refugee camp., Methods: DPP technology was used to examine documentation speed, sequence, and behavior. The data log of the digital pens used to fill in the documentation was analyzed, and each pen stroke in a field was recorded using a timestamp. Documentation time was the difference between first and last stroke on the paper, which includes clinical examination and translation., Results: For three months, 495 data sets were recorded. After corrections had been made, 421 data sets were considered valid and subjected to further analysis. The median documentation time was 41:41 min (interquartile range 29:54 min; mean 45:02 min; SD 22:28 min). The documentation of vital signs ended up having the strongest effect on the overall time of documentation. Furthermore, filling in the free-text field clinical findings or therapy or measures required the most time (mean 16:49 min; SD 20:32 min). Analysis of the documentation sequence revealed that the final step of coding the diagnosis was a time-consuming step that took place once the form had been completed., Conclusions: We concluded that medical documentation using DPP technology leads to both an increase in documentation speed and data quality through the compliance of the data recorders who regard the tool to be convenient in everyday routine. Further analysis of more data sets will allow optimization of the documentation form used. Thus, DPP technology is an effective tool for the medical documentation process in refugee camps., (©Kai Kehe, Roland Girgensohn, Walter Swoboda, Dan Bieler, Axel Franke, Matthias Helm, Martin Kulla, Kerstin Luepke, Thomas Morwinsky, Markus Blätzinger, Katalyn Rossmann. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 19.08.2019.)

Background: In South Africa it is compulsory to submit a satisfactory portfolio of learning to gain entrance to the national exit examination of the College of Family Physicians and to qualify as a family physician. A paper-based portfolio has been implemented thus far and the need for an electronic portfolio (e-portfolio) was identified. The aim of the study was to describe and evaluate the implementation of an e-portfolio for the training of family medicine registrars in the Western Cape province of South Africa., Methods: Mixed methods were used. A quasi-experimental study evaluated paper- and e-portfolios from the same 28 registrars in 2015 compared to 2016. Semi-structured interviews were conducted with 11 registrars or supervisors to explore their experiences of using the e-portfolio. Quantitative data was analysed in the Statistical Package for Social Sciences and qualitative data in Atlas.ti., Results: Most respondents found the e-portfolio easier to use and more accessible. It made progress easier to monitor and provided sufficient evidence of learning. Feedback was made easier and more explicit. There were concerns regarding face-to-face feedback being negatively affected. It was suggested to have a feedback template to further improve feedback. Several aspects were significantly better in the e-portfolio such as feedback on the registrar's general behaviour, alignment with learning outcomes, less feedback based on hearsay and acknowledgement of the feedback by the registrar. Although not statistically significant, there was an increase in the usage of the e-portfolio, compared to the paper portfolio., Conclusion: In general, the e-portfolio is an improvement on the paper-based portfolio. It is easier to access, more user-friendly and less cumbersome. It makes feedback and monitoring of progress and development of registrars easier and more visible and provides sufficient evidence of learning. Its implementation throughout South Africa is recommended.

The use of electronic documentation systems (EDS) has the potential to ensure timely, up-to-date and comprehensive patient health-related information is available and accessible to nurses regardless of their physical location. Despite the benefits of EDS, nurses' low intention to use such systems is well documented, which may predict behavioural usage. Further, limited knowledge exists about nurses' intention to use EDS in the context of home care. The aim of the study was to examine factors that influence nurses' intention of using EDS in home care practice. The conceptual model framing this study is adapted from the Unified Theory of Acceptance and Use of Technology (UTAUT). A cross-sectional design was used. Nurses (N = 217) currently practicing within the home care sector in Ontario participated in the study. An online survey using adapted and psychometrically sound quantitative instruments was administered. Data were analyzed with descriptive statistics and hierarchical linear regression. Performance expectancy, attitude, social influence and facilitating conditions had significant, positive and direct effects on nurses' behavioural intention. Effort expectancy and nurses' individual characteristics (i.e., age, level of education and technology experience) were not found to have a direct and/or moderating influence on nurses' intention to use EDS in home care practice. Theory, practice and research implications for the findings are presented and discussed., (Copyright © 2019 Longwoods Publishing.)

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group ( P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

Purpose: With the current wide adoption of electronic health records (EHRs) by ophthalmologists, there are widespread concerns about the amount of time spent using the EHR. The goal of this study was to examine how the amount of time spent using EHRs as well as related documentation behaviors changed 1 decade after EHR adoption., Design: Single-center cohort study., Participants: Six hundred eighty-five thousand three hundred sixty-one office visits with 70 ophthalmology providers., Methods: We calculated time spent using the EHR associated with each individual office visit using EHR audit logs and determined chart closure times and progress note length from secondary EHR data. We tracked and modeled how these metrics changed from 2006 to 2016 with linear mixed models., Main Outcome Measures: Minutes spent using the EHR associated with an office visit, chart closure time in hours from the office visit check-in time, and progress note length in characters., Results: Median EHR time per office visit in 2006 was 4.2 minutes (interquartile range [IQR], 3.5 minutes), and increased to 6.4 minutes (IQR, 4.5 minutes) in 2016. Median chart closure time was 2.8 hours (IQR, 21.3 hours) in 2006 and decreased to 2.3 hours (IQR, 18.5 hours) in 2016. In 2006, median note length was 1530 characters (IQR, 1435 characters) and increased to 3838 characters (IQR, 2668.3 characters) in 2016. Linear mixed models found EHR time per office visit was 31.9±0.2% (P < 0.001) greater from 2014 through 2016 than from 2006 through 2010, chart closure time was 6.7±0.3 hours (P < 0.001) shorter from 2014 through 2016 versus 2006 through 2010, and note length was 1807.4±6.5 characters (P < 0.001) longer from 2014 through 2016 versus 2006 through 2010., Conclusions: After 1 decade of use, providers spend more time using the EHR for an office visit, generate longer notes, and close the chart faster. These changes are likely to represent increased time and documentation pressure for providers. Electronic health record redesign and new documentation regulations may help to address these issues., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Play specialists work closely with doctors and nurses to improve outcomes and the hospital experience for young patients. Documentation is an important but challenging aspect of their work. It should be incorporated into their workflow through a user-friendly format to minimise workload and record information that is useful to the multidisciplinary team (MDT) at the same time., Aim: To develop a play specialist progress note format and to evaluate its capacity to generate useful information for the MDT., Method: A questionnaire and inductive coding were used to develop a format incorporating the advantages of a structure focused on capturing useful information and the narrative style of documentation. The format, Well-being, Interests, Strategies, Evaluation (WISE), was aligned with play specialists' workflow and allowed for documentation of play in children's hospital care. Post-implementation evaluation comprised a usefulness survey and qualitative analyses of documentation., Results: Perception of the usefulness of the WISE format was positive with nurses giving higher ratings than doctors. Gaps were identified for further investigation and improvement., Conclusion: Play specialists could either adapt the WISE format or adopt a similar process in developing and evaluating documentation suitable for their own work environment., Competing Interests: None declared, (©2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Objectives Few studies have examined the extent to which providers assess pregnancy intentions during clinical encounters. Our objective was to assess temporal trends in documentation of patient pregnancy intentions in electronic health records (EHR). Methods In this retrospective observational study using EHR data from 627,399 female patients visiting 214 family planning centers in 2012-2014, we assessed changes in the prevalence of pregnancy intention documentation with piecewise log-binomial regression models. We examined bivariate associations between patient/visit characteristics and pregnancy intention documentation in each year, and associations between patients' pregnancy intentions and contraceptive methods. Results The proportion of patients with a documented pregnancy intention increased sharply from the end of 2012 (42%) to the midpoint of 2013 (85%; adjusted quarterly prevalence ratio [APR] = 1.40, 95% CI 1.36-1.45). Thereafter, the rate of change slowed as documentation approached the maximum possible frequency (93%; APR = 1.01, 95% CI 1.00-1.02). Documentation varied by all patient/visit characteristics in 2012 and 2013; in 2014, there were no clinically significant differences. Among patients with a documented intention, 97% were not planning a pregnancy in the next year. Women not planning a pregnancy were more likely to use a most/moderately effective contraceptive method than those planning a pregnancy (73 vs. 35%, p < 0.0001). Conclusions for Practice Improvements in pregnancy intention documentation co-occurred with changes to EHR templates (e.g., placement of structured data fields) and with provider-focused initiatives promoting reproductive life planning. Patients' pregnancy intentions aligned with contraceptive use; however, these findings cannot address whether assessment of intentions affects contraceptive use.

The presence of scribes in various specialties, including internal medicine, is being heralded as a way to decrease clinician documentation time and burnout. Many medical school applicants become scribes to understand life as a doctor and gain clinical experience. Scribing is already perceived by some as a new key to successfully gaining entrance to medical school. One season of our admissions data showed that scribes were more likely to be admitted (OR = 1.61). Scribes may also inadvertently make it harder for medical schools to secure clinical placements for medical students. While trained scribes are highly valued by providers struggling to deal with increasing documentation burdens, supervising or training scribes also requires time that cannot be devoted to teaching. Medical documentation duties could provide valuable learning experiences for medical students. The recent ruling allowing medical students to contribute directly to clinical documentation without requiring redocumentation by supervisors gives medical schools and clinician-educators an opportunity to consider the unintended consequences of the scribe movement for medical education. Educators should consider when and how students can maximize the educational benefits of participating in patient documentation despite the templated methods commonly used in electronic health record (EHR) systems.

Despite their widespread use, electronic medical records have created frustrations for physicians, especially those working in busy hospital emergency departments. After a brief discussion of the causes of the problems, a potential solution-the use of medical scribes-is presented. The extant literature regarding results obtained following the implementation of medical scribes in emergency departments is reviewed and some conclusions regarding the future of this phenomenon are presented. The future looks quite bright for use of medical scribes in hospitals' emergency departments.

Targets and indicators set at the global level are powerful tools that govern health systems in low-income countries. Skilled birth attendance at a health facility is an important indicator for monitoring maternal mortality reduction worldwide. This paper examines how health workers negotiate policy implementation through the translation of clinical care into registries and reports. It does so by analysing the links between the global policy of institutional births and the role of documentation in the provision of birth care in primary health centres in Burkina Faso. Observations of health workers' practices in four primary maternity units (one urban, one semi-urban and two rural) conducted over a 12-week period in 2011-2012 are analysed alongside 14 in-depth interviews with midwives and other health workers. The findings uncover the magnitude of reporting demands that health workers experience and the pressure placed on them to provide the 'right' results, in line with global policy objectives. The paper describes the way in which they document inaccurate accounts, for example by completing the labour surveillance tool partograph after birth, thus transforming it into a 'postograph', to adhere to the expectations of health district officers. We argue that the drive for the 'right' numbers might encourage inaccurate reporting practices and it can feed into policies that are incapable of addressing the realities experienced by frontline health workers and patients. The focus on producing indicators of good care can divert attention from actual care, with profound implications for accountability at the health centre level., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. The following study aims to assess the coding accuracy of medical student documentation., Design: Retrospective chart review identified patient encounters in a surgery clinic that contained documentation by both a faculty member and a third-year medical student. Records were de-identified and assigned a level of service (LOS) and diagnostic code by trained, expert coders. Differences in LOS and diagnostic code were then compared between medical student and faculty documentation., Setting: A single academic health system., Participants: Third-year medical students., Results: 80 full patient evaluations and 20 postoperative visits were analyzed. Median faculty and student LOS was 4 (range 3-4) and 3 (range 0-4) respectively (p < 0.001). Students failed to document a sufficient number of elements in the evaluation, failed to specify studies ordered, and documented low medical decision making. Diagnostic code was concordant between students and faculty for only 31% of documentation., Conclusion: Student documentation of clinical encounters is coded at a lower LOS than faculty documentation. These results likely reflect the lack of education regarding E/M coding in medical school, which is integral to real world practice., Summary: Accurate medical documentation is critical to the correct diagnostic coding and billing of a medical encounter. We found that compared to faculty documentation of the same patient evaluations, student documentation was typically coded at a lower level of service and assigned a different diagnostic code by professional medical coders. Addressing these topics in medical school may better prepare students for real-world practice., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Fellows of the Royal College of Physicians and Surgeons of Canada are required to participate in assessment activities for all new 5-year cycles beginning on or after January 2014 to meet the maintenance of certification program requirements. This study examined the assessment activities which psychiatrists reported in their maintenance of certification e-portfolios to determine the types and frequency of activities reported; the resultant learning, planned learning, and/or changes to the practice they planned or implemented; and the interrelationship between the types of assessment activities, learning that was affirmed or planned, and changes planned or implemented., Methods: A total of 5000 entries from 2195 psychiatrists were examined. A thematic analysis drawing on the framework analysis was undertaken of the 2016 entries., Results: There were 3841 entries for analysis; 1159 entries did not meet the criteria for assessment. The most commonly reported activities were self-assessment programs, feedback on teaching, regular performance reviews, and chart reviews. Less frequent were direct observation, peer supervision, and reviews by provincial medical regulatory authorities. In response to the data, psychiatrists affirmed that their practices were appropriate, identified gaps they intended to address, planned future learning, and/or planned or implemented changes. The assessment activities were internally or externally initiated and resulted in no or small changes (accommodations and adjustments) or redirections., Discussion: Psychiatrists reported participating in a variety of assessment activities that resulted in variable impact on learning and change. The study underscores the need to ensure that assessments being undertaken are purposeful, relevant, and designed to enable identification of outcomes that impact practice.

Workarounds are commonplace in healthcare settings. An increase in the use of electronic health records has led to an escalation of workarounds as healthcare professionals cope with systems which are inadequate for their needs. Closely related to this, the documentation of vital signs in electronic health records has been problematic. The accuracy and completeness of vital sign documentation has a direct impact on the recognition of deterioration in a patient's condition. We examined workflow processes to identify workarounds related to vital signs in a 372-bed hospital in Sweden. In three clinical areas, a qualitative study was performed with data collected during observations and interviews and analysed through thematic content analysis. We identified paper workarounds in the form of handwritten notes and a total of eight pre-printed paper observation charts. Our results suggested that nurses created workarounds to allow a smooth workflow and ensure patients safety.

Background: Clinical performance measures often require documentation of patient counseling by healthcare providers. Little is known about whether such measures encourage delivery of counseling or merely its documentation., Objective: To assess changes in provider documentation of alcohol counseling and patient report of receiving alcohol counseling in the Veterans Administration (VA) from 2009 to 2012., Design: Retrospective time-series analysis., Participants: A total of 5413 men who screened positive for unhealthy alcohol use at an outpatient visit and responded to a confidential mailed survey regarding alcohol counseling from a VA provider in the prior year., Main Measures: Rates of provider documentation of alcohol counseling in the electronic health record and patient report of such counseling on the survey were assessed over 4 fiscal years. Annual rates were calculated overall and with patients categorized into four mutually exclusive groups based on their own reports of alcohol counseling (yes/no) and whether alcohol counseling was documented by a provider (yes/no)., Key Results: Provider documentation of alcohol counseling increased 23.6% (95% CI: 17.0, 30.2), from 59.4% to 83.0%, while patient report of alcohol counseling showed no significant change (4.0%, 95% CI: -2.3, 10.3), increasing from 66.1% to 70.1%. An 18.7% (95% CI: 11.7, 25.7) increase in the proportion of patients who reported counseling that was documented by a provider largely reflected a 14.7% decline (95% CI: 8.5, 20.8) in the proportion of patients who reported alcohol counseling that was not documented by a provider. The proportion of patients who did not report counseling but whose providers documented it did not show a significant change (4.9%, 95%CI: 0.0, 9.9)., Conclusions: If patient report is accurate, increased rates of documented alcohol counseling in the VA from 2009 to 2012 predominantly reflected improved documentation of previously undocumented counseling rather than delivery of additional counseling or increased documentation of counseling that did not meaningfully occur.

Background: Electronic health records (EHRs), despite their positive attributes, increase physician workload and decrease efficiency. The aim of this study was to evaluate the impact of scribes in the Inflammatory Bowel Disease Clinic on improvement of the physician-patient relationship, physician productivity, clinical efficiency, and achievement of some Physician Quality Reporting System (PQRS) metrics., Methods: We analyzed of pre- and postscribe data between fiscal years 2015 (FY15) and 2016 (FY16) using data from patients at the Inflammatory Bowel Clinic at the University of Florida. The main outcomes were patient satisfaction scores (PSS), qualitative physician interview, clinic appointment lengths, work relative value units (wRVUs), level of coding, revenue, and PQRS data on bone density screening and vaccination., Results: PSS increased from 6.8/10 to 9.2/10 (P < 0.01), clinic appointment length decreased by 13.5 minutes (P < 0.05), and documentation stress decreased. Clinic visits increased by 76, leading to an increase in work RVUs by 332.55, total charges billed by $71,439, and total charges collected by $27,387 between the first quarters of FY15 and FY16. The extra revenue for the first quarter was 536% higher than the salary of the scribe for the same period ($4302.84). There was a 1.8-fold increase in referrals for bone density scans and 2.9-fold and 4.8-fold increases in vaccination rates for influenza and pneumonia, respectively., Conclusions: The use of scribes improved the physician-patient relationship, clinical efficiency, physician productivity, bone density screening, and vaccinations for flu and pneumonia. If adopted by health systems, it may lead to significant cost savings and improved clinical outcomes.

We describe the development and design of a smartphone app-based system to create inpatient progress notes using voice, commercial automatic speech recognition software, with text processing to recognize spoken voice commands and format the note, and integration with a commercial EHR. This new system fits hospital rounding workflow and was used to support a randomized clinical trial testing whether use of voice to create notes improves timeliness of note availability, note quality, and physician satisfaction with the note creation process. The system was used to create 709 notes which were placed in the corresponding patient's EHR record. The median time from pressing the Send button to appearance of the formatted note in the Inbox was 8.8 min. It was generally very reliable, accepted by physician users, and secure. This approach provides an alternative to use of keyboard and templates to create progress notes and may appeal to physicians who prefer voice to typing., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A growing demand for transparency in medicine has the potential to strain the doctor-patient relationship. While information can empower patients, unrestricted patient access to the electronic medical record may have unintended consequences. Medical documentation is often written in language that is inaccessible to people without medical training, and without guidance, patients have no way to interpret the constellation of acronyms, diagnoses, treatments, impressions, and arguments that appear throughout their own chart. Additionally, full transparency may not allow physicians the intellectual or clinical freedom they need to authentically express questions, problematic impressions, and concerns about the patient's clinical and psychosocial issues. This article examines the ethical challenges of transparency in the digital era and suggests that selective redaction may serve as a means to maintain transparency, affirm physician's discretion, and uphold the core values of the doctor-patient relationship amidst disruptive technological change.

Background: Residency programs use electronic portfolios (efolios) to organize data, track resident performance, and sometimes teach and assess lifelong learning (LLL) skills. Published studies on efolios in graduate medical education are mostly descriptions of implementation at individual institutions., Methods: An anonymous online survey was sent to 199 pediatric residency program directors across the United States. Efolio usage patterns were described and compared between program directors that perceived efolios effective at fostering LLL and those that did not., Results: Surveys were completed by 82 of 199 program directors (41%), and 55% used efolios. The 20% (9 of 45) of program directors that believed efolios were effective at teaching LLL more often used self-assessment (88% vs. 50%, p = 0.05) and goal-setting (75% vs. 40%, p = 0.03) functionalities. Common efolio challenges included limited usability and difficulty integrating data. Most non-users (65%) would like to invest in efolios., Conclusions: Respondents reported technical and convenience-related challenges to efolio use, which need to be addressed for efolios to meet their potential as valuable learning tools. The use of self-assessments and goal-setting features was associated with program directors' perceptions that efolios were effective at fostering LLL.

Background: Physician burnout is becoming an epidemic, due to the pressures of being productive, an imperfect electronic health record (EHR) system, and limited face-to-face time with patients. Poor usability in EHR-user interface can force users to go through more steps (i.e. more clicks on the computer) in accomplishing a task., Objective: This increased 'click burden' is a source of frustration for physicians. In the light of increased click burden and time due to meaningful use requirements, there is a need to improve the physician's experience by creating innovations in EHR., Method: This case study describes an attempt by physicians at NewYork-Presbyterian Brooklyn Methodist Hospital to enhance the EHR experience with more efficient methods of documentation, chart review, ordering and patient safety., Results: The EHR innovations trialled in this study were: a mobile documentation application; abnormal test results auto-populated into an EHR patient summary; physician alerts to reduce inappropriate test ordering; and a system of safety alerts on a dashboard. These innovations led to decreased click burden and allowed physicians to spend less time on the computer and more time with patients., Conclusion: Physician-driven changes to EHR systems have the potential to streamline virtual workflows and the management of health information and to improve patient safety, reduce physician burnout and increase physician job satisfaction.