Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3100 — Perceived Threats to Safety Using Electronic Documentation

Weir CR (SLC TREP) , Nebeker J (SLC TREP), Rappaport H (OCIO Office of Technology)

Electronic documentation is a core component of VHA support of continuity of care practices. The main objective of this study is to identify hazards related to the use of electronic documentation in the VA CPRS system.

We selected ten sites based on agreement to participate, geographical diversity, and size. At each site, a primary care clinic was randomly selected. Specific staff were selected as available on the day of the site visit. Semi-structured interviews were conducted with embedded observations of patient care. Specific questions included: How accurate, complete, or comprehensive is CPRS documentation? What do you think is the biggest threat to accuracy in terms of CPRS documentation? Do you engage in copy and paste activities? Have you seen any harm related to documentation practices? In addition, clinicians were asked to demonstrate their use of CPRS. For example, if a clinician said that they used a template, they were asked to demonstrate the template and how they used it. During this demonstration, clinicians were asked to “think aloud”. The interviews were taped, transcribed, and analyzed for responses to selected questions and emerging themes.

We conducted 88 interviews (14 nurses, 53 ordering providers, 8 pharmacists, 2 dieticians, 3 clerks, and 8 social workers). The qualitative themes of information overload, trust, workload, and integration were identified. Over two-thirds of the interviewees indicated concern with the accuracy of the content of electronic documentation. Copy and paste and templated notes were considered the highest threat to patient safety. However, over 80% of providers admitted to using both functions. Information overload was mentioned by 90% of the interviewees as somewhat of a problem. Specific concerns differed across provider types. Providers reported frequently seeing serious errors but could not recall that they resulted in actual patient harm.

Electronic documentation provides both significant benefit as well as potential harm. Providers commonly use features of CPRS that they believe to adversely affect the quality of documentation.

Substantial opportunities exist to improve the VA’s Information System and, in turn, improve the continuity of care.