Documenting transitional information in EMR

  • Authors:
  • Yunan Chen

  • Affiliations:
  • University of California Irvine, Irvine, CA, USA

  • Venue:
  • Proceedings of the SIGCHI Conference on Human Factors in Computing Systems
  • Year:
  • 2010

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Abstract

An observational study was conducted to examine EMR-based documentation in an Emergency Department (ED), with an emphasis on computerized documentation activities in the complex flow of clinical processes. This study revealed a gap between the formal EMR documentation and the actual clinical workflow, which leads ED staff to rely on intermediate - transitional artifacts to facilitate their work. The analysis of these transitional artifacts in four different clinical workflows shows that the EMR system's inability to document procedural information, capture key information, and present information according to the actual clinical workflow are accountable for leading to the use of transitional artifacts. The findings of this study call for designing EMR system not only for keeping patients' formal records, but also for documenting transitional information in the chart-writing process.