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Awareness of the Care Team in Electronic Health Records.
Appl Clin Inform. 2011; 2(4):395-405.AC

Abstract

OBJECTIVE:

To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center.

METHODS:

We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation.

RESULTS:

For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent.

CONCLUSIONS:

The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.

Authors+Show Affiliations

Department of Biomedical Informatics, Columbia University, New York, NY.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

22574103

Citation

Vawdrey, David K., et al. "Awareness of the Care Team in Electronic Health Records." Applied Clinical Informatics, vol. 2, no. 4, 2011, pp. 395-405.
Vawdrey DK, Wilcox LG, Collins S, et al. Awareness of the Care Team in Electronic Health Records. Appl Clin Inform. 2011;2(4):395-405.
Vawdrey, D. K., Wilcox, L. G., Collins, S., Feiner, S., Mamykina, O., Stein, D. M., Bakken, S., Fred, M. R., & Stetson, P. D. (2011). Awareness of the Care Team in Electronic Health Records. Applied Clinical Informatics, 2(4), 395-405.
Vawdrey DK, et al. Awareness of the Care Team in Electronic Health Records. Appl Clin Inform. 2011;2(4):395-405. PubMed PMID: 22574103.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Awareness of the Care Team in Electronic Health Records. AU - Vawdrey,David K, AU - Wilcox,Lauren G, AU - Collins,Sarah, AU - Feiner,Steven, AU - Mamykina,Olena, AU - Stein,Daniel M, AU - Bakken,Suzanne, AU - Fred,Matthew R, AU - Stetson,Peter D, PY - 2012/5/11/entrez PY - 2011/1/1/pubmed PY - 2011/1/1/medline SP - 395 EP - 405 JF - Applied clinical informatics JO - Appl Clin Inform VL - 2 IS - 4 N2 - OBJECTIVE: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center. METHODS: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation. RESULTS: For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent. CONCLUSIONS: The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety. SN - 1869-0327 UR - https://www.unboundmedicine.com/medline/citation/22574103/Awareness_of_the_Care_Team_in_Electronic_Health_Records_ L2 - http://www.thieme-connect.com/DOI/DOI?10.4338/ACI-2011-05-RA-0034 DB - PRIME DP - Unbound Medicine ER -
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