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ERIC Number: ED527790
Record Type: Non-Journal
Publication Date: 2010
Pages: 103
Abstractor: As Provided
Reference Count: 0
ISBN: ISBN-978-1-1245-6791-4
ISSN: N/A
Electronic Documentation Support Tools and Text Duplication in the Electronic Medical Record
Wrenn, Jesse
ProQuest LLC, Ph.D. Dissertation, Columbia University
In order to ease the burden of electronic note entry on physicians, electronic documentation support tools have been developed to assist in note authoring. There is little evidence of the effects of these tools on attributes of clinical documentation, including document quality. Furthermore, the resultant abundance of duplicated text and information in the clinical record has not been well studied. We applied known computational methods in a novel manner to study redundancy. Using a modified Levenshtein edit distance algorithm, we quantified narrative redundancy across a corpus of documents. We also tracked information duplicated across document types within patient admissions. Finally, we compiled evidence about the effects of electronic documentation support tools on document quality, and studied the effect of electronic documentation support tools on various document attributes. We found that there exists significant redundancy in signout, progress and discharge summary notes, and that information is frequently copied from several document types, including various reports. We also found that electronic documentation support tools appear to have a negative effect on document quality overall, and that their use effects document length and content density. Our findings suggest future directions for investigation, especially with respect to the consequences of redundancy in the electronic medical record. We must seek to enable and encourage the use of smart information duplication, while maximizing the efficiency of clinical document creation. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]
ProQuest LLC. 789 East Eisenhower Parkway, P.O. Box 1346, Ann Arbor, MI 48106. Tel: 800-521-0600; Web site: http://www.proquest.com/en-US/products/dissertations/individuals.shtml
Publication Type: Dissertations/Theses - Doctoral Dissertations
Education Level: Adult Education
Audience: N/A
Language: English
Sponsor: N/A
Authoring Institution: N/A