Writing and reading in the electronic health record: an entirely new world

dc.creator	Lauri Lopp
dc.creator	Heeyoung Han
dc.date	2013-02-01T00:00:00Z
dc.date.accessioned	2015-07-20T22:08:22Z
dc.date.available	2015-07-20T22:08:22Z
dc.identifier	10.3402/meo.v18i0.18634
dc.identifier	1087-2981
dc.identifier	https://doaj.org/article/efc5087c57f948b69d599b2d86ebcb7e
dc.identifier.uri	http://evidence.thinkportal.org/handle/123456789/11967
dc.description	Background: Electronic health records (EHRs) are structured, distributed documentation systems that differ from paper charts. These systems require skills not traditionally used to navigate a paper chart and to produce a written clinic note. Despite these differences, little attention has been given to physicians’ electronic health record (EHR)-writing and -reading competence. Purposes: This study aims to investigate physicians’ self-assessed competence to document and to read EHR notes; writing and reading preferences in an EHR; and demographic characteristics associated with their perceived EHR ability and preference. Methods: Fourteen 5-point Likert scale items, based on EHR system characteristics and a literature review, were developed to measure EHR-writing and -reading competence and preference. Physicians in the midwest region of the United States were invited via e-mail to complete the survey online from February to April 2011. Factor analysis and reliability testing were conducted to provide validity and reliability of the instrument. Correlation and regression analysis were conducted to pursue answers to the research questions. Results: Ninety-one physicians (12.5%), from general and specialty fields, working in inpatient and outpatient settings, participated in the survey. Despite over 3 years of EHR experience, respondents perceived themselves to be incompetent in EHR writing and reading (Mean = 2.74, SD = 0.76). They preferred to read succinct, narrative notes in EHR systems. However, physicians with higher perceived EHR-writing and -reading competence had less preference toward reading succinct (r= − 0.33, p<0.001) and narrative (r= − 0.36, p<0.001) EHR notes than physicians with lower perceived EHR competence. Physicians’ perceived EHR-writing and -reading competence was strongly related to their EHR navigation skills (r=0.55, p<0.0001). Conclusions: Writing and reading EHR documentation is different for physicians. Maximizing navigation skills can optimize non-linear EHR writing and reading. Pedagogical questions remain related to how physicians and medical students are able to retrieve correct information effectively and to understand thought patterns in collectively lengthier and sometimes fragmented EHR chart notes.
dc.language	English
dc.publisher	Co-Action
dc.relation	http://med-ed-online.net/index.php/meo/article/view/18634/pdf_1
dc.relation	https://doaj.org/toc/1087-2981
dc.rights	CC BY
dc.source	Medical Education Online, Vol 18, Iss 0, Pp 1-7 (2013)
dc.subject	electronic health record (EHR)
dc.subject	electronic medical record (EMR)
dc.subject	reading
dc.subject	documentation
dc.subject	navigation
dc.subject	Special aspects of education
dc.subject	LC8-6691
dc.subject	Education
dc.subject	L
dc.subject	DOAJ:Education
dc.subject	DOAJ:Social Sciences
dc.subject	Medicine (General)
dc.subject	R5-920
dc.subject	Medicine
dc.subject	R
dc.subject	DOAJ:Medicine (General)
dc.subject	DOAJ:Health Sciences
dc.subject	Special aspects of education
dc.subject	LC8-6691
dc.subject	Education
dc.subject	L
dc.subject	DOAJ:Education
dc.subject	DOAJ:Social Sciences
dc.subject	Medicine (General)
dc.subject	R5-920
dc.subject	Medicine
dc.subject	R
dc.subject	DOAJ:Medicine (General)
dc.subject	DOAJ:Health Sciences
dc.subject	Special aspects of education
dc.subject	LC8-6691
dc.subject	Education
dc.subject	L
dc.subject	Medicine (General)
dc.subject	R5-920
dc.subject	Medicine
dc.subject	R
dc.subject	Special aspects of education
dc.subject	LC8-6691
dc.subject	Education
dc.subject	L
dc.subject	Medicine (General)
dc.subject	R5-920
dc.subject	Medicine
dc.subject	R
dc.subject	Special aspects of education
dc.subject	LC8-6691
dc.subject	Education
dc.subject	L
dc.subject	Medicine (General)
dc.subject	R5-920
dc.subject	Medicine
dc.subject	R
dc.title	Writing and reading in the electronic health record: an entirely new world
dc.type	article