Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators: Table 1
Open accessAbstract
OBJECTIVE: Clinical documentation is central to the medical record and so to a range of healthcare and business processes. As electronic health record adoption expands, computerized provider documentation (CPD) is increasingly the primary means of capturing clinical documentation. Previous CPD studies have focused on particular stakeholder groups and sites, often limiting their scope and conclusions. To address this, we studied multiple stakeholder groups from multiple sites across the USA. METHODS: We conducted 14 focus groups at five Department of Veterans Affairs facilities with 129 participants (54 physicians or practitioners, 34 nurses, and 37 administrators). Investigators qualitatively analyzed resultant transcripts, developed categories linked to the data, and identified emergent themes. RESULTS: Five major themes related to CPD emerged: communication and coordination; control and limitations in expressivity; information availability and reasoning support; workflow alteration and disruption; and trust and confidence concerns. The results highlight that documentation intertwines tightly with clinical and administrative workflow. Perceptions differed between the three stakeholder groups but remained consistent within groups across facilities. CONCLUSIONS: CPD has dramatically changed documentation processes, impacting clinical understanding, decision-making, and communication across multiple groups. The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows. Current CPD systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated 'paper-chart' paradigm. These findings should inform those implementing CPD systems now and future plans for more effective CPD systems.
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The note generation task from doctor-patient encounters and its associated electronic medical record documentation is one of the most arduous and time-consuming tasks for physicians.
“The note generation task from doctor-patient encounters, and its associated electronic medical record documentation, is one of the most arduous time-consuming tasks for physicians.”
From Aci-bench: a Novel Ambient Clinical Intelligence Dataset for Benchmarking Automatic Visit Note Generation (2023) · cites this paper as [2]
The Results (‘Workflow alteration and disruption’) describe electronic documentation as time-consuming, and the Discussion calls the time and effort of creating notes major workflow disruptors. The paper does not compare note generation with physicians’ other tasks or establish that it is among their most arduous. (LLM, conf=0.84)
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- Authors
- Embi, P. J., Weir, C., Efthimiadis, E. N., Thielke, S. M., Hedeen, A. N., & Hammond, K. W.
- Affiliations
- University of Utah (US)
- University of Washington (US)
- VA Puget Sound Health Care System (US)
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2013-07
- Volume
- 20
- Issue
- 4
- Pages
- 718-726
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC3721152
- OpenAlex
- W2147733805
- Cited by
- 74
- References
- 54
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 4 · 2023: 7 · 2022: 9 · 2021: 2 · 2020: 6 · 2019: 7 · 2018: 7 · 2017: 6 · 2016: 4 · 2015: 8 · 2014: 8 · 2013: 2
- FWCI
- 12.65
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by-nc-nd
- Locations
- Journal of the American Medical Informatics Association (publishedVersion, cc-by-nc-nd)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Veterans Affairs
- Health Services Research and Development
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- electronic health records, clinical documentation, stakeholder perspectives, physicians, nurses, hospital administrators, clinical workflow, information availability, workflow disruption, Department of Veterans Affairs
- MeSH terms
- Administrative Personnel, Attitude of Health Personnel, Attitude to Computers, Documentation, Humans, Nurses, Physicians, United States, United States Department of Veterans Affairs, Medical Records Systems, Computerized, Focus Groups, Electronic Health Records
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