Reengineering Clinician Documentation

Reengineering Clinician Documentation – Ergonomics and Human Factors in Healthcare


Dr. Nick van Terheyden
Voice of the Doctor #VoiceoftheDr
LinkedIn Profile, Twitter: @drnic1

Clinical documentation is an increasingly time consuming challenge for clinicians offering significant pressures that are vested in a range of requirements not always tightly aligned with clinical decision making. (See Documentation Coding Burdens)

Electronic Medical Records (EMR’s) have added to the burden of information capture and while the prevailing view is that EMR’s improve care (and care coordination) making more information available to the expanded care team. As was aptly demonstrated this week with the discovery of a long lost patient record for President Lincoln from Dr. Charles A. Leale, good clinical documentation includes all the details and in particular the narrative. I have said this before in relation to Henry VIII’s medical record here.

Today on VoiceoftheDoctor I will be speaking with Ruthann Lipman, DO from the Department of Otolaryngology, Millcreek Community Hospital and David Eibling, MD, FACS from the Department of Otolaryngology, University of Pittsburgh and VA Pittsburgh who are presenting a paper at Human Factors and Ergonomics Society (HFES) this October titled: “Re- engineering the Healthcare Team: Meeting the needs of Providers with Information Specialists.”

The paper looks at re-engineering the healthcare team in a large otolaryngology practice through the addition of information specialists to increased productivity. They studied the effect of transferring information system tasks to specialists who support the provides in their day to day interactions with the technology and patients. Using technology together with skilled scribes who were remote offering efficiencies that offset the costs associated with both the labor and technology costs of implementation. This is an interesting blend of old and new and a realistic alternative for some who remain challenged with the complexity of EMR interactions and prefer to maintain a patient focus during the clinical encounter.

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A version of this article first appeared on Voice of the Doctor and is used with the author’s permission.