Quite a bit of our current work regarding EHRs has concerned the use of patient progress notes; sometimes also referred to as visit note. “A patient progress note is a clinical document… describing a patient’s status and the physician’s assessments and care plan for the patient.” (Wilcox et al 2010). In order to construct a progress note, the clinician must acquire, review and comment on various aspects of the patient’s data (e.g. lab results, information from medical rounds, medications, procedures, tests, etc.) so that they may determine the health of the patient and what to include in the current note (Wilcox et al 2010).
How are progress notes documented?
Currently, there are a few ways in which progress notes are created:
Clinical templates: these are pre-formatted notes which provide a standard protocol for documenting specific conditions. These notes are “point and click” entry or keyboard entry based on likely problems that a patient may have (McKesson 2010). Sound simple? Not for all. “It’s not easy to document everything that occurs during an office visit by clicking boxes” (Schumacher and Lew 2010).
Dictation: some physicians continue to dictate progress notes despite successful transition to an EHR because of familiarity. Drawback of this format includes the fact that the data may not be available for reporting purposes and “transcription services sacrifices the financial return on investment of using an EHR" (McKesson 2010).
Voice recognition: voice recognition seems like a viable alternative which helps reduce the need for keyboard entry but also comes with its own concerns (McKesson 2010).
So what’s the problem?
Most EHR applications are database-oriented (symptom, diagnosis, treatment, and then billing) which do not conform nicely to the complex and varied practice of medicine. EHR's force the health providers to change how they write a progress note and what many EHRs end up doing is complicating things by adding unnecessary step or elements that get in the way. It has also been stated that “the progress note, though once helpful, is now the single biggest hindrance to physician efficiency in the use and adoption of the EHR" (Sanders 2009)
It seems that progress notes have become a burden to write and a burden to read but are still regarded as being indispensable because they help to communicate the patient’s health information. That is to say, the usability of the EHR has been one of the big barriers to EHR implementation for quite some time. It has also been demonstrated in a survey that 90% of doctors are “concerned” or “very concerned” about the usability of EHRs as being a leading obstacle to adoption (Nuance Communications, Inc. 2009).
It was also documented in this survey that physicians cited the following as “important” or “very important”:
- Access to medical records faster without waiting for records to come out of traditional manual transcription (90 percent)
- More complete patient reports, with higher levels of detail on the patient’s condition and visit (83 percent)
- Better caregiver-to-caregiver communication based on improved reporting that is more accessible and easily shared (83 percent)
- Improved documentation by pairing the EHR point-and-click template with physician narrative (79 percent)
What are we doing to help?
· Observing clinical users to understand their workflows and primary tasks
o These primary tasks should be up front in the EHR and readily accessible
o Secondary tasks should be accessed via clear, logical flow
o Develop information architecture based on users’ workflows
o Understand context of use (For example, not all applications are suitable for mobile.)
· Simplify feature set available in the EHR
· If using a form, improve the experience by attending to workflows and typical behaviors
o Systems can provide warnings not available on forms
o System can progressively display information only when/ if needed
· Support ability to set defaults so that users don’t have to scroll through lists of form/ templates that don’t apply to them
· Use terms consistent with user group’s vocabulary
About the Author
Anneliis Tosine is a User Experience Researcher in the UX Team at Macadamian. Anneliis’ background is in Biomedical Engineering with a focus on clinical applications and user-centered design.