Managing the Life Cycle of Electronic Clinical Documents

Overview

Journal J Am Med Inform Assoc

Publisher Oxford University Press

Specialty Medical Informatics

Date 2006 Apr 20

PMID 16622169

Citations 5

Authors

Thomas H Payne

Gail Graham

Affiliations

Soon will be listed here.

Abstract

Objective: To develop a model of the life cycle of clinical documents from inception to use in a person's medical record, including workflow requirements from clinical practice, local policy, and regulation.

Design: We propose a model for the life cycle of clinical documents as a framework for research on documentation within electronic medical record (EMR) systems. Our proposed model includes three axes: the stages of the document, the roles of those involved with the document, and the actions those involved may take on the document at each stage. The model includes the rules to describe who (in what role) can perform what actions on the document, and at what stages they can perform them. Rules are derived from needs of clinicians, and requirements of hospital bylaws and regulators.

Results: Our model encompasses current practices for paper medical records and workflow in some EMR systems. Commercial EMR systems include methods for implementing document workflow rules. Workflow rules that are part of this model mirror functionality in the Department of Veterans Affairs (VA) EMR system where the Authorization/ Subscription Utility permits document life cycle rules to be written in English-like fashion.

Conclusions: Creating a model of the life cycle of clinical documents serves as a framework for discussion of document workflow, how rules governing workflow can be implemented in EMR systems, and future research of electronic documentation.

Citing Articles

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Lin T, Eroglu Z, Carvajal R, Markowitz J Methods Mol Biol. 2020; 2194:35-44.

PMID: 32926360 PMC: 7787345. DOI: 10.1007/978-1-0716-0849-4_3.

Physician-Driven Management of Patient Progress Notes in an Intensive Care Unit.

Wilcox L, Lu J, Lai J, Feiner S, Jordan D Proc SIGCHI Conf Hum Factor Comput Syst. 2016; 2010:1879-1888.

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Standardizing Clinical Document Names Using the HL7/LOINC Document Ontology and LOINC Codes.

Chen E, Melton G, Engelstad M, Sarkar I AMIA Annu Symp Proc. 2011; 2010:101-5.

PMID: 21346949 PMC: 3041326.

The automation of clinical trial serious adverse event reporting workflow.

London J, Smalley K, Conner K, Smith J Clin Trials. 2009; 6(5):446-54.

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Governance for personal health records.

Reti S, Feldman H, Safran C J Am Med Inform Assoc. 2008; 16(1):14-7.

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References

Berner E, Detmer D, Simborg D . Will the wave finally break? A brief view of the adoption of electronic medical records in the United States. J Am Med Inform Assoc. 2004; 12(1):3-7. PMC: 543824. DOI: 10.1197/jamia.M1664. View

Payne T, Hirschmann J, Helbig S . The elements of electronic note style. J AHIMA. 2003; 74(2):68, 70. View

Dolin R, Alschuler L, Boyer S, Beebe C, Behlen F, Biron P . HL7 Clinical Document Architecture, Release 2. J Am Med Inform Assoc. 2005; 13(1):30-9. PMC: 1380194. DOI: 10.1197/jamia.M1888. View

Brown S, Lincoln M, Hardenbrook S, Petukhova O, Rosenbloom S, Carpenter P . Derivation and evaluation of a document-naming nomenclature. J Am Med Inform Assoc. 2001; 8(4):379-90. PMC: 130083. DOI: 10.1136/jamia.2001.0080379. View

Tornvall E, Wilhelmsson S, Wahren L . Electronic nursing documentation in primary health care. Scand J Caring Sci. 2004; 18(3):310-7. DOI: 10.1111/j.1471-6712.2004.00282.x. View

Hurdle J, Weir C, Roth B, Hoffman J, Nebeker J . Critical gaps in the world's largest electronic medical record: Ad Hoc nursing narratives and invisible adverse drug events. AMIA Annu Symp Proc. 2004; :309-12. PMC: 1480185. View

Rosenbloom S, Grande J, Geissbuhler A, Miller R . Experience in implementing inpatient clinical note capture via a provider order entry system. J Am Med Inform Assoc. 2004; 11(4):310-5. PMC: 436080. DOI: 10.1197/jamia.M1461. View

Goossen W, Ozbolt J, Coenen A, Park H, Mead C, Ehnfors M . Development of a provisional domain model for the nursing process for use within the Health Level 7 reference information model. J Am Med Inform Assoc. 2004; 11(3):186-94. PMC: 400517. DOI: 10.1197/jamia.M1085. View

Weir C, Hurdle J, Felgar M, Hoffman J, Roth B, Nebeker J . Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003; 42(1):61-7. View

10.

McDonald C . The barriers to electronic medical record systems and how to overcome them. J Am Med Inform Assoc. 1997; 4(3):213-21. PMC: 61236. DOI: 10.1136/jamia.1997.0040213. View

11.

Staes C, Huff S, Evans R, Narus S, Tilley C, Sorensen J . Development of an information model for storing organ donor data within an electronic medical record. J Am Med Inform Assoc. 2005; 12(3):357-63. PMC: 1090468. DOI: 10.1197/jamia.M1689. View

12.

Payne T, Kalus R, Zehner J . Evolution and use of a note classification scheme in an electronic medical record. AMIA Annu Symp Proc. 2006; :599-603. PMC: 1560646. View

13.

Van Eaton E, Horvath K, Lober W, Rossini A, Pellegrini C . A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005; 200(4):538-45. DOI: 10.1016/j.jamcollsurg.2004.11.009. View

14.

Hammond K, Helbig S, Benson C, Brathwaite-Sketoe B . Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc. 2004; :269-73. PMC: 1480345. View