1. Documenting Transitional Information
in EMR
Yunan Chen
Presenter: Parul Seth
University of California, Irvine
INF 295 Topics In Health Informatics
November 27th, 2013
1

2. BACKGROUND
2

3. Paper Medical Records Vs. Electronic
Medical Records (EMR)
3

4. Electronic Medical Records
Healthcare IT Reform plan
says, “the majority of US
hospitals will soon switch to
EMR systems”.
EMR is an information system that
creates, gathers, manages and stores digital
versions of patients’ paper charts within one
healthcare organization system. Essentially, a
documentation tool that supports clinical
documentation activities.
Improved Work Efficiency
Increased Patient Safety
Unintended
Consequences
Inefficiency
Better Accountability & Billing
Increased
Workload
4

5. Problems
Studies show that the documentation workload has increased after
using the EMR system.
Continued use of old paper records or workarounds.
Ruling out paper is tough! Paper supports micro mobility, it is
“handlable, manipulable, portable, dismantable”, easily organized.
“Working records”, “provisional information”, “scraps” are used to
facilitate team collaboration
Though relevant categories of medical records are defined in the
healthcare IT systems, “the practices through which the document
is written, read and used within consultation have been largely
ignored.”
It is important to study “the computerized clinical documentation in complex clinical
environments, especially the issues of efficiency associated with the EMR usage.”
5

6. Study Goal
“To examine EMR based documentation in an Emergency
Department (ED), with an emphasis on computerized
documentation activities in the complex flow of clinical
processes. With a focus on clinical workflow issues associated
with the computerized documentation activities.”
6

7. Why Emergency Department (ED)?
Work Efficiency is a dominant concern
Patients experience entire treatment process in a short stay
ED workflow notoriously complex due to diverse disease type and high time-constraint
“A great opportunity to study documentation from different users and to see how the
EMR system does or does not support the actual clinical workflow.”
7

8. Parallel Documentation Practice: Transitional
Artifacts
This study will reveal a parallel documentation practice that records informal
information facilitating the flow of clinical work. The informal documentation
is considered as Transitional Artifacts that carry the information needed to
facilitate EMR-based documentation.
8

9. METHODOLOGY
9

10. Study & Participants
 Observational Study at the Emergency Department
(ED) of a large regional hospital located in the west
coast.
 57 clinical staff members, including 1 consulting
physician, 11 attending's, 6 residents, 28 registered
nurses, and 5 ED technicians.
+ Admitting staff members, case managers, discharge
case planners, as well as social workers, working on the
floor.
”This study consisted of a field observation of the computerized clinical
documentation in the ED.”
10

11. Emergency Department @ Field Site
 4 major units: a pediatric ED, an urgent care unit, a trauma
center, and the main ED.
 The main ED has 2 nursing stations and a MD station surrounded
by 12 patient rooms.
 The field observation covered the clinical documentation process
in patients’ waiting rooms, triages, nursing stations, MD
stations, patient rooms and other public areas in the ED.
Main ED Area Map in the EMR
11

12. ED Documentation @ Field Site





EMR system went live in July 2008.
Old paper record system not used.
Computers all over on the ED floor.
3 Computer-on-wheels (COW)
ED layout designed to allow timely access to
EMR.
 Tracker System: Another information
system to track patient’s flows and show
where patients are on the ED floor.
 Only one single path for patient treatment
observed to illustrate the use of transitional
artifacts (many other paths are possible).
 Single path: A patient walks into ED and is
later admitted for hospitalization.
12

13. Data and Data Collection
•Examining overall activities related to the ED patient flow with an emphasis on the documentation-related
activities, the signoff activities for ED doctors and nurses, the ED admitting and discharging processes, as well as the
shift change meetings.
Field
•Both day and night shifts, approximately 50% observation during ED peak times
Observation
Data
Extraction
Analysis
•Data related to the ED documentation extracted from notes.
•Data was then sorted & listed by roles of the ED staff and the treatment process.
•Notes were then analyzed using an open coding technique to identify recurring patterns of documentation behaviors
adopted by the ED staff.
•Findings were not drawn from one individual patient treatment flow, but based on a synthesis of the recurring
behaviors demonstrated by multiple ED staff in the same work role and linked together according to the steps of a
patient’s ED visit procedures.
•The patterns revealed in the study were further verified with the ED staff to ensure their validities.
Verification
” 120 hours of field observation were performed over a period of 8 weeks. Each
observation 4-5 Hours, with brief notes jotted down, detailed notes transcribed later.”
13

14. FINDINGS OVERVIEW
14

15. ED Workflow
15
“The ED documentation handled by four main roles and two information systems
following patients’ treatment process.”

16. Happy Thanksgiving 
16

17. References
 Chen, Y. Documenting transitional information in EMR.
Proceedings of the 28th international conference on Human
factors in computing systems, ACM (2010), 1787–1796.
 All images have been searched and downloaded from Google
Images
17