What Do Physicians Read (and Ignore) in Electronic Progress Notes?

P.J. Brown; J.L. Marquard; B. Amster; M. Romoser; J. Friderici; S. Goff; D. Fisher

doi:10.4338/ACI-2014-01-RA-0003

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2014; 05(02): 430-444
DOI: 10.4338/ACI-2014-01-RA-0003

Research Article

Schattauer GmbH

What Do Physicians Read (and Ignore) in Electronic Progress Notes?

Authors

P.J. Brown

¹Division of Clinical Informatics, Baystate Health, Springfield, MA, USA
J.L. Marquard

²College of Engineering, University of Massachusetts Amherst, Amherst, MA, USA
B. Amster

²College of Engineering, University of Massachusetts Amherst, Amherst, MA, USA
M. Romoser

²College of Engineering, University of Massachusetts Amherst, Amherst, MA, USA
J. Friderici

³Department of Epidemiology & Biostatistics, Baystate Health, Springfield, MA, USA
S. Goff

³Department of Epidemiology & Biostatistics, Baystate Health, Springfield, MA, USA
D. Fisher

²College of Engineering, University of Massachusetts Amherst, Amherst, MA, USA

Abstract

Summary

Objective: Several studies have documented the preference for physicians to attend to the impression and plan section of a clinical document. However, it is not clear how much attention other sections of a document receive. The goal of this study was to identify how physicians distribute their visual attention while reading electronic notes.

Methods: We used an eye-tracking device to assess the visual attention patterns of ten hospitalists as they read three electronic notes. The assessment included time spent reading specific sections of a note as well as rates of reading. This visual analysis was compared with the content of simulated verbal handoffs for each note and debriefing interviews.

Results: Study participants spent the most time in the “Impression and Plan” section of electronic notes and read this section very slowly. Sections such as the “Medication Profile”, “Vital Signs” and “Laboratory Results” received less attention and were read very quickly even if they contained more content than the impression and plan. Only 9% of the content of physicians’ verbal handoff was found outside of the “Impression and Plan.”

Conclusion: Physicians in this study directed very little attention to medication lists, vital signs or laboratory results compared with the impression and plan section of electronic notes. Optimizing the design of electronic notes may include rethinking the amount and format of imported patient data as this data appears to largely be ignored.

Citation: Brown PJ, Marquard JL, Amster B, Romoser M, Friderici J, Goff S, Fisher D. What do physicians read (and ignore) in electronic progress notes? Appl Clin Inf 2014; 5: 430–444 http://dx.doi.org/10.4338/ACI-2014-01-RA-0003

Keywords

Electronic health records - documentation - attention - information seeking behavior - humans

Full Text

References

References
1 Roukema J, Los RK, Bleeker SE, van Ginneken AM, van der Lei J, Moll HA. Paper versus computer: Feasibility of an electronic medical record in general pediatrics. Pediatrics 2006; 117 (Suppl. 01) 15-21.
2 Walsh SH. The clinician’s perspective on electronic health records and how they can affect patient care. BMJ 2004; 328 7449 1184-1187.
3 Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med 2009; 169 (Suppl. 02) 108-114.
4 Kumagai AK. A conceptual framework for the use of illness narratives in medical education. Acad Med 2008; 83 (Suppl. 07) 653-658.
5 Johnson SB, Bakken S, Dine D, Hyun S, Mendonça E, Morrison F, Bright T, Van Vleck T, Wrenn J, Stetson P. An electronic health record based on structured narrative. J Am Med Inform Assoc 2008; 15 (Suppl. 01) 54-64.
6 Johnson KB, Cowan J. Clictate: a computer-based documentation tool for guideline-based care. J Med Syst 2002; 26 (Suppl. 01) 47-60.
7 Hartzband P, Groopman J. Off the record — avoiding the pitfalls of going electronic. N Engl J Med 2008; 358 (16) 1656-1658.
8 Payne TH, Patel R, Beahan S, Zehner J. The physical attractiveness of electronic physician Nnotes. AMIA Annu Symp Proc 2010; 2010: 622-626.
9 Weir CR, Nebeker JR. Critical issues in an electronic documentation system. AMIA Annu Symp Proc 2007: 786-790.
10 Reichert D, Kaufman D, Bloxham B, Chase H, Elhadad N. Cognitive analysis of the summarization of longitudinal patient records. AMIA Annu Symp Proc 2010; 2010: 667-671.
11 Zheng K, Padman R, Johnson MP, Diamond HS. An interface-driven analysis of user interactions with an electronic health records system. J Am Med Inform Assoc 2009; 16 (Suppl. 02) 228-237.
12 Shoolin J, Ozeran L, Hamann C, Bria W. Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation. Appl Clin Inform 2013; 4 (Suppl. 02) 293-303.
13 Lin CT, McKenzie M, Pell J, Caplan L. Health care provider satisfaction with a new electronic progress note format: SOAP vs APSO format. JAMA Intern Med 2013; 173 (Suppl. 02) 160-162.
14 Hahn JS, Bernstein JA, McKenzie RB, King BJ, Longhurst CA. Rapid implementation of inpatient electronic physician documentation at an academic hospital. Appl Clin Inform 2012; 3 (Suppl. 02) 175-185.
15 Duchowski AT. Eye tracking methodology: Theory and practice . 2nd ed. London: Springer-Verlag; 2007
16 Rayner K. Eye movements in reading and information processing: 20 years of research. Psychol Bull 1998; 124 (Suppl. 03) 372-422.
17 Jacob RJ, Karn KS. Eye tracking in human-computer interaction and usability research: Ready to deliver the promises. In: The mind’s eye: Cognitive and applied aspects of eye movement research. Hyona J, Radach R, Deubel H, (eds.) Oxford: Elsevier; 2003. p 573-605
18 Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med 2007; 22 (10) 1470-1474.
19 Crabtree BF, Miller WL. editors. Doing Qualitative Research. 2nd ed. London: Sage; 1999
20 Coiera E. When conversation is better than computation. J Am Med Inform Assoc 2000; 7 (Suppl. 03) 277-286.
21 Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: A perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011; 18 (Suppl. 02) 181-186.
22 Stetson PD, Morrison FP, Bakken S, Johnson SB. eNote Research Team.. Preliminary development of the physician documentation quality instrument. J Am Med Inform Assoc 2008; 15 (Suppl. 04) 534-541
23 Stetson PD, Bakken S, Wrenn JO, Siegler EL. Assessing electronic note quality using the physician documentation quality instrument (PDQI-9). Appl Clin Inform 2012; 3 (Suppl. 02) 164-174.