Abstract

Background: Electronic medical records (EMRs) serve a variety of purposes in healthcare, from disease management and pharmacy order entry, to billing, reimbursement and population-based research. Increasing organizational pressures for throughput, including strict time requirements for completion of documentation, have resulted in unprecedented cognitive and communication challenges for primary care clinicians as “people work” (providing care) and “paper work” (EMR completion) vie for attention in the exam room. Though the patient/clinician relationship remains “the center of medicine” conceptually, the patient/ clinician/ computer relationship adds the challenge of simultaneously inputting data into the EMR to the task of patient centered communication. These competing demands often result in multi-tasking, which threatens both the quality of the patient/clinician relationship and the accuracy of documentation. As well, failure to complete patient notes by the end of the visit or regular business hours may shift the burden of documentation from the workplace into the home where it competes with family time and self-care. Either way, the EMR challenges clinician resilience, defined as successfully negotiating, managing and adapting to significant sources of stress. Objectives: The overall objective of this proposal is to optimize Primary Care Clinicians (PCCs) use of computer-based technology in managing the administrative burdens of preparing for, enacting and documenting ambulatory visits. The specific aims are to: 1) identify EMR documentation practices that relate to high quality Veteran centered, well- documented care that is satisfying on both sides of the stethoscope; 2) describe the range of strategies highly effective clinicians use to prepare for, enact, and complete visit documentation; and 3) test the feasibility of adapting an existing EMR curriculum for use with VA PCCs. Methods: This is a multimethod project. For Aim 1, we will describe variations in exam room computer use. Documentation completion rates will be calculated using available administrative data and ethnographic observation. Clinicians’ real-time preparation, and post visit documentation during business hours, will be observed and patient visits will be videotaped and analyzed. Aim 2 will identify clinicians’ EMR practices associated with Veteran-centered communication, documentation accuracy and resilience. Measures include: EMR accuracy and completeness, clinicians’ psychological resilience, and Veterans’ perception of patient centeredness. The results will be triangulated with the ethnographic observations and video recorded encounters. Cognitive task interviews will be utilized to understand the mental models used to guide decisions about how, when and where PCCs use the EMR and how these models relate to perceptions of resilience. Aim 3 will test the feasibility of adapting an existing EMR curriculum for use with VA PCCs. Innovation: The proposed project breaks new ground with its focus on the relationship of pressure to complete EMR documentation and its effects on clinician resilience. It will provide VHA with evidence, guidelines and a curriculum to reduce the chronic stresses associated with EMR use in preparing for, enacting, and post visit documentation. At the same time, the project will identify best practices for promoting Veteran-centered communication, note accuracy, and timeliness. Situating medical documentation within the broader context of workplace resilience for clinicians who experience feelings of burnout is a critical area of focus in theVHA.

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DRA: Health Systems

DRE: Treatment - Observational, TRL - Applied/Translational

Keywords: Patient-Provider Interaction, Practice Patterns/Trends, Provider Education

MeSH Terms: None at this time.