Use of electronic clinical documentation: time spent and team interactions

Objective To measure the time spent authoring and viewing documentation and to study patterns of usage in healthcare practice. Design Audit logs for an electronic health record were used to calculate rates, and social network analysis was applied to ascertain usage patterns. Subjects comprised all care providers at an urban academic medical center who authored or viewed electronic documentation. Measurement Rate and time of authoring and viewing clinical documentation, and associations among users were measured. Results Users spent 20e103 min per day authoring notes and 7e56 min per day viewing notes, with physicians spending less than 90 min per day total. About 16% of attendings’ notes, 8% of residents’ notes, and 38% of nurses’ notes went unread by other users, and, overall, 16% of notes were never read by anyone. Viewing of notes dropped quickly with the age of the note, but notes were read at a low but measurable rate, even after 2 years. Most healthcare teams (77%) include...

• Type: Journal
• Year: 2011
• Where: JAMIA
• Authors: George Hripcsak, David K. Vawdrey, Matthew R. Fred, Susan B. Bostwick
• Keywords: Algorithms, Electronic Health Record, JAMIA 2011, Measurement Rate, Nurses Notes