Clinicians' reasoning as reflected in electronic clinical note-entry and reading/retrieval: a systematic review and qualitative synthesis

Objective

To describe the literature exploring the use of electronic health record (EHR) systems to support creation and use of clinical documentation to guide future research.

Materials and Methods

We searched databases including MEDLINE, Scopus, and CINAHL from inception to April 20, 2018, for studies applying qualitative or mixed-methods examining EHR use to support creation and use of clinical documentation. A qualitative synthesis of included studies was undertaken.

Results

Twenty-three studies met the inclusion criteria and were reviewed in detail. We briefly reviewed 9 studies that did not meet the inclusion criteria but provided recommendations for EHR design. We identified 4 key themes: purposes of electronic clinical notes, clinicians' reasoning for note-entry and reading/retrieval, clinicians' strategies for note-entry, and clinicians' strategies for note-retrieval/reading. Five studies investigated note purposes and found that although patient care is the primary note purpose, non-clinical purposes have become more common. Clinicians' reasoning studies (n = 3) explored clinicians' judgement about what to document and represented clinicians' thought process in cognitive pathways. Note-entry studies (n = 6) revealed that what clinicians document is affected by EHR interfaces. Lastly, note-retrieval studies (n = 12) found that "assessment and plan" is the most read note section and what clinicians read is affected by external stimuli, care/information goals, and what they know about the patient.

Conclusion

Despite the widespread adoption of EHRs, their use to support note-entry and reading/retrieval is still understudied. Further research is needed to investigate approaches to capture and represent clinicians' reasoning and improve note-entry and retrieval/reading.

Clinical Informatics Researcher's Desiderata for the Data Content of the Next Generation Electronic Health Record

OBJECTIVE

Clinical informatics researchers depend on the availability of high-quality data from the electronic health record (EHR) to design and implement new methods and systems for clinical practice and research. However, these data are frequently unavailable or present in a format that requires substantial revision. This article reports the results of a review of informatics literature published from 2010 to 2016 that addresses these issues by identifying categories of data content that might be included or revised in the EHR.

MATERIALS AND METHODS

We used an iterative review process on 1,215 biomedical informatics research articles. We placed them into generic categories, reviewed and refined the categories, and then assigned additional articles, for a total of three iterations.

RESULTS

Our process identified eight categories of data content issues: Adverse Events, Clinician Cognitive Processes, Data Standards Creation and Data Communication, Genomics, Medication List Data Capture, Patient Preferences, Patient-reported Data, and Phenotyping.

DISCUSSION

These categories summarize discussions in biomedical informatics literature that concern data content issues restricting clinical informatics research. These barriers to research result from data that are either absent from the EHR or are inadequate (e.g., in narrative text form) for the downstream applications of the data. In light of these categories, we discuss changes to EHR data storage that should be considered in the redesign of EHRs, to promote continued innovation in clinical informatics.

CONCLUSION

Based on published literature of clinical informaticians' reuse of EHR data, we characterize eight types of data content that, if included in the next generation of EHRs, would find immediate application in advanced informatics tools and techniques.

Good Medicine and Good Healthcare Demand Good Information (Systems)

The demand for evidence-based health informatics and benchmarking of 'good' information systems in health care gives an opportunity to continue reporting on recent papers in the German journal GMS Medical Informatics, Biometry and Epidemiology (MIBE) here. The publications in focus deal with a comparison of benchmarking initiatives in German-speaking countries, use of communication standards in telemonitoring scenarios, the estimation of national cancer incidence rates and modifications of parametric tests. Furthermore papers in this issue of MIM are introduced which originally have been presented at the Annual Conference of the German Society of Medical Informatics, Biometry and Epidemiology. They deal as well with evidence and evaluation of 'good' information systems but also with data harmonization, surveillance in obstetrics, adaptive designs and parametrical testing in statistical analysis, patient registries and signal processing.