Busy clinicians struggle with productivity and usability in electronic health record systems (EHRs). While previous studies have investigated documentation practices and strategies in the inpatient setting, outpatient documentation and review practices by clinicians using EHRs are relatively unknown. In this study, we look at clinicians’ patterns of note review in the EHR during outpatient office visits in ophthalmology. Key findings from this study are that the number and percentage of notes reviewed is very low, there is variation between providers, specialties, and users, and staff access more notes than physicians. These findings suggest that the vast majority of content in the EHR is not being used by clinicians; improved EHR designs would better present this data and support the information needs of outpatient clinicians.
Learning Objective 1: After participating in this session, the learner should be better able to quantify the number of clinical notes outpatient ophthalmologists access in the EHR during an office visit.
Michelle Hribar (Presenter)
David Biermann, OHSU
Isaac Goldstein, OHSU
Michael Chiang, OHSU