Clinical Encounter Information Flow: Applications In Evaluating Medical Documentation Tools

Abstract

There is little research on how clinically relevant concepts are transferred from a patient, through a healthcare provider, and then to a resultant clinical note. This study tested whether clinical information flow, defined as the transfer of concepts from patient to note, can be traced. The study's investigators also analyzed the impact of a clinical documentation tool on note content. Healthcare providers, designated as clinical simulation study subjects, generated clinical notes via two documentation tools. The simulation utilized standardized patient scenario descriptions (PSDs). Independent physician reviewers identified clinical concepts present in the PSDs and in resultant clinic notes. Reviewers identified a total of 256 unique clinical concepts across all PSDs. Of these, a total of 122 unique concepts overlapped for the PSDs and resultant notes from both documentation tools. Additionally, the dictation-based and computer-based notes shared 103 distinct concepts not found in the PSDs. This study's findings suggest that both computer-based and dictation-based tools are subject to clinical concept loss. Templates may have eased documentation, partly explaining the greater concept count for computer-based notes. This study found that tracing information flow in a clinical simulation encounter is a valid method for evaluating medical documentation tools. Clinical note template availability also likely impacts healthcare provider documentation.