A hospital-wide transition from paper to digital problem-oriented clinical notes

Summary

Objectives: To evaluate the use, usability, and physician satisfaction of a locally developed problem-oriented clinical notes application that replaced paper-based records in a large Dutch university medical center.

Methods: Using a clinical notes database and an application event log file and a cross-sectional survey of usability, authors retrospectively analyzed system usage for medical specialties, users, and patients over 4 years. A standardized questionnaire measured usability. Authors analyzed the effects of sex, age, professional experience, training hours, and medical specialty on user satisfaction via univariate analysis of variance. Authors also examined the correlation between user satisfaction in relation to users’ intensity of use of the application.

Results: In total 1,793 physicians used the application to record progress notes for 219,755 patients. The overall satisfaction score was 3.2 on a scale from 1 (highly dissatisfied) to 5(highly satisfied). A statistically significant difference occurred in satisfaction by medical specialty, but no statistically significant differences in satisfaction took place by sex, age, professional experience, or training hours. Intensity of system use did not correlate with physician satisfaction.

Conclusions: By two years after the start of the implementation, all medical specialties utilized the clinical notes application. User satisfaction was neutral (3.2 on a 1–5 scale). Authors believe that the significant factors facilitating this transition mirrored success factors reported by other groups: a generic, consistent, and transparent design of the application; intensive collaboration; continuous monitoring; and an incremental rollout.

Citation: Cillessen FHJM, de Vries Robbé PF, Biermans MCJ. A hospital-wide transition from paper to digital problem-oriented clinical note. Appl Clin Inform 2017; 8: 502–514 https://doi.org/10.4338/ACI-2016-08-RA-0137

Keywords

Electronic health records and systems - problem-oriented medical records - evaluation - satisfaction - physician

Human Subject Research Approval

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by the privacy officer as a representative of the board of directors of the Radboud University Medical Center, Nijmegen, the Netherlands.

• References

• 1 Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, Taylor R. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood) 2005; 24 (05) 1103-1117. doi: 10.1377/hlthaff.24.5.1103
• 2 Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144 (10) 742-752. doi:10.7326/0003–4819–144–10–200605160–00125
• 3 Jones SS, Rudin RS, Perry T, Shekelle PG. Health information technology: an updated systematic review with a focus on meaningful use. Ann Intern Med 2014; 160 (01) 48-54. doi: 10.7326/M13–1531
• 4 Kuhn T, Basch P, Barr M, Yackel T. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med 2015; 162 (04) 301-303.
• 5 Ammenwerth E, Spötl HP. The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians’ activities. Methods Inf Med 2009; 48 (01) 84-91. doi: 10.3414/ME0569
• 6 Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278 (11) 593-600. doi: 10.1056/NEJM196803142781105
• 7 Schultz JR. A history of the PROMIS Technology: An effective human interface. In: Goldberg A. editor. A History of Personal Workstations. Reading, MA: AMC Press; 1988
• 8 Walker HK, Hurst JW, Woody MF. (eds) Applying the Problem Oriented System. Medcom Press: New York; 1973
• 9 Mellner C, Selander H, Wolodarski J. The computerized problem-oriented medical record at Karolinska Hospital: Format and function, users’ acceptance and patient attitude to questionnaire. Methods Inf Med 1976; 15 (01) 11-20.
• 10 Simons SM, Cillessen FH, Hazelzet JA. Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature. BMC Med Inform Decis Mak. 2016 16: 102. doi: 10.1186/s12911–016–0341–0
• 11 Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras JP, Mattke S, Pitchforth E, Quigley DD, Brook RH, Crosson FJ, Tutty M. Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy. Rand Corporation. 2013 http://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf Last accessed March 2016.
• 12 Rosenbaum L. Transitional chaos or enduring harm? The EHR and the disruption of medicine. N Engl J Med 2015; 373 (17) 1585-1588.
• 13 Love JS, Wright A, Simon SR, Jenter CA, Soran CS, Volk LA, Bates DW, Poon EG. Are physicians’ perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?. J Am Med Inform Assoc 2012; 19 (04) 610-614. doi: 10.1136/amiajnl-2011–000544
• 14 Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag. 2013 10, 1c. http://perspectives.ahima.org/impact-of-electronic-health-record-systems-on-information-integrity-quality-and-safety-implications Last accessed February 2016.
• 15 Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: The National Academies Press; 2011
• 16 AmericanEHR Partners. Physicians Use of EHR Systems 2014. http://www.americanehr.com/research/reports/Physicians-Use-of-EHR-Systems-2014.aspx Last accessed March 2016.
• 17 Meeks DW, Smith MW, Taylor L, Sittig DF, Scott J M, Singh H. An analysis of electronic health record-related patient safety concerns. Journal of the American Medical Informatics Association 2014; 21 (06) 1053-1059. doi: 10.1136/amiajnl-2013–002578
• 18 Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy 2011; 4: 47-55. doi: 10.2147/RMHP.S12985
• 19 Makam AN, Lanham HJ, Batchelor K, Samal L, Moran B, Howell-Stampley T, Kirk L, Cherukuri M, Santini N, Leykum LK, Halm EA. Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers. BMC Med Inform Decis Mak 2013; 13: 86. doi: 10.1186/1472–6947–13–86
• 20 the International Organization for standardization. https://www.iso.org/obp/ui/#iso:std:iso:9241:-11:ed-1:v1:en Last accessed October 2016.
• 21 Staggers N, Xiao Y, Chapman L. Debunking health IT usability myths. Appl Clin Inform 2013; 4 (02) 241-250. doi: 10.4338/ACI-2013–03-IE-0016
• 22 Cillessen FH, de Vries Robbe PF. Modeling problem-oriented clinical notes. Methods Inf Med 2012; 51 (06) 507-515. doi: 10.3414/ME11–01–0064
• 23 Lewis JR. IBM computer usability satisfaction questionnaires: psychometric evaluation and instructions for use. International Journal of Human-Computer Interaction 1995; 7 (01) 57-78. doi: 10.1080/10447319509526110
• 24 Nielsen J. What is Usability? In: Usability Engineering. San Francisco, CA: Morgan Kaufmann Publishers; 1993: 23-48
• 25 Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems: United States, 2011. NCHS Data Brief 2012; 98: 1-8.
• 26 Manchikanti L, Benyamin RM, Falco FJ, Hirsch JA. Metamorphosis of medicine in the United States: a carrot and stick policy of electronic medical records. Pain Physician 2014; 17 (06) E671-E680.
• 27 American College of Physicians. Survey of Clinicians: User Satisfaction with Electronic Health Records Has Decreased Since. 2010 https://www.acponline.org/newsroom/ehrs_survey.htm Last accessed March 2016.
• 28 Menachemi N, Powers T, Au DW, Brooks RG. Predictors of physician satisfaction among electronic health record system users. J Healthc Qual 2010; 32 (01) 35-41. doi: 10.1111/j.1945–1474.2009.00062.x
• 29 Ellsworth MA, Dziadzko M, O’Horo JC, Farrell AM, Zhang J, Herasevich V. An appraisal of published usability evaluations of electronic health records via systematic review. Journal of the American Medical Informatics Association. 2016 ocw046. doi: http://dx.doi.org/10.1093/jamia/ocw046
• 30 Payne TH, TenBroek AE, Fletcher GS, Labuguen MC. Transition from paper to electronic inpatient physician notes. J Am Med Inform Assoc 2010; 17: 108e11. doi: 10.1197/jamia.M3173
• 31 Bossen C. Evaluation of a computerized problem-oriented medical record in a hospital department: does it support daily clinical practice?. Int J Med Inform 2007; 76 (08) 592-600. doi: 10.1016/j.ijmedinf.2006.04.007
• 32 Jia-lin L, Siru L, Fei L. Physician satisfaction with electronic medical record in a huge hospital (China). Stud Health Technol Inform 2013; 192: 920.
• 33 Alharthi H, Youssef A, Radwan S, Al-Muallim S, Zainab A. Physician satisfaction with electronic medical records in a major Saudi Government hospital. Journal of Taibah University Medical Sciences 2014; 9 (03) 213-218. doi: 10.1016/j.jtumed.2014.01.004
• 34 Tilahun B, Fritz F. Comprehensive Evaluation of Electronic Medical Record System Use and User Satisfaction at Five Low-Resource Setting Hospitals in Ethiopia. JMIR Medical Informatics 2015; 3 (02) e22. doi: 10.2196/medinform.4106
• 35 Nguyen L, Bellucci E, Nguyen LT. Electronic health records implementation: an evaluation of information system impact and contingency factors. Int J Med Inform 2014; 83 (11) 779-796. doi: 10.1016/j.ijmedinf.2014.06.011
• 36 Wright E, Marvel J. Electronic health records: postadoption physician satisfaction and continued use. Health Care Manag (Frederick) 2012; 31 (03) 259-267. doi: 10.1097/HCM.0b013e3182619e90
• 37 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 (02) 181-186. doi: 10.1136/jamia.2010.007237
• 38 Ajami S, Bagheri-Tadi T. Barriers for adopting electronic health records (EHRs) by physicians. Acta Inform Med 2013; 21 (02) 129-134. doi: 10.5455/aim.2013.21.129–134
• 39 Ho YX, Gadd CS, Kohorst KL, Rosenbloom ST. A qualitative analysis evaluating the purposes and practices of clinical documentation. Appl Clin Inform 2014; 5 (01) 153-168. doi:10.4338/ACI-2013–10-RA-0081.
• 40 Trentman TL, Mueller JT, Ruskin KJ, Noble BN, Doyle CA. Adoption of anesthesia information management systems by US anesthesiologists. J Clin Monit Comput 2011; 25: 129. doi:10.1007/s10877–011–9289-x
• 41 Hanauer DA, Branford GL, Greenberg G, Kileny S, Couper MP, Zheng K, Choi SW. Two-year longitudinal assessment of physicians’ perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist?. Journal of the American Medical Informatics Association. Jul 2016; ocw077; doi: 10.1093/jamia/ocw077
• 42 Podsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol 2003; 88 (05) 879-903. doi: 10.1037/0021–9010.88.5.879
• 43 Ancker JS, Kern LM, Edwards A, Nosal S, Stein DM, Hauser D, Kaushal R. How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use. J Am Med Inform Assoc. 2014 doi: 10.1136/amiajnl-2013–002627.
• 44 Jones CD, Holmes GM, Lewis SE, Thompson KW, Cykert S, DeWalt DA. Satisfaction with electronic health records is associated with job satisfaction among primary care physicians. Inform Prim Care 2013; 21 (01) 18-20. doi: 10.14236/jhi.v21i1.27
• 45 O’Connell RT, Cho C, Shah N, Brown K, Shiffman RN. Take note(s): differential EHR satisfaction with two implementations under one roof. J Am Med Inform Assoc 2004; 11 (01) 43-49. doi: 10.1197/jamia.M1409