Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes

Christopher A. March, Gretchen Scholl, Renee K. Dversdal, Matthew Richards, Leah M. Wilson, Vishnu Mohan, Jeffrey (Jeff) Gold

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Background With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training. Objective To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes. Methods Three months after beginning their internship, 32 interns participated in an EHR simulation designed to assess patterns in note writing and generation. Each intern was given a simulated chart and instructed to create a daily progress note. Notes were graded for use of copy-paste, macros, and accuracy of presented data. Results A total of 31 out of 32 interns (97%) completed the exercise. There was wide variance in use of macros to populate data, with multiple macro types used for the same data category. Three-quarters of notes contained either copy-paste elements or the elimination of active medical problems from the prior days' notes. This was associated with a significant number of quality issues, including failure to recognize a lack of deep vein thrombosis prophylaxis, medications stopped on admission, and issues in prior discharge summary. Conclusions Interns displayed wide variation in the process of creating progress notes. Additional studies are being conducted to determine the impact EHR-based simulation has on standardization of note content.

Original languageEnglish (US)
Pages (from-to)237-240
Number of pages4
JournalJournal of graduate medical education
Volume8
Issue number2
DOIs
StatePublished - May 1 2016

Fingerprint

Electronic Health Records
Ointments
Internship and Residency
Internal Medicine
Venous Thrombosis
Exercise

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes. / March, Christopher A.; Scholl, Gretchen; Dversdal, Renee K.; Richards, Matthew; Wilson, Leah M.; Mohan, Vishnu; Gold, Jeffrey (Jeff).

In: Journal of graduate medical education, Vol. 8, No. 2, 01.05.2016, p. 237-240.

Research output: Contribution to journalArticle

March, Christopher A. ; Scholl, Gretchen ; Dversdal, Renee K. ; Richards, Matthew ; Wilson, Leah M. ; Mohan, Vishnu ; Gold, Jeffrey (Jeff). / Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes. In: Journal of graduate medical education. 2016 ; Vol. 8, No. 2. pp. 237-240.
@article{de2b86d2cccb4344b56949af63ef4c2f,
title = "Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes",
abstract = "Background With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training. Objective To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes. Methods Three months after beginning their internship, 32 interns participated in an EHR simulation designed to assess patterns in note writing and generation. Each intern was given a simulated chart and instructed to create a daily progress note. Notes were graded for use of copy-paste, macros, and accuracy of presented data. Results A total of 31 out of 32 interns (97{\%}) completed the exercise. There was wide variance in use of macros to populate data, with multiple macro types used for the same data category. Three-quarters of notes contained either copy-paste elements or the elimination of active medical problems from the prior days' notes. This was associated with a significant number of quality issues, including failure to recognize a lack of deep vein thrombosis prophylaxis, medications stopped on admission, and issues in prior discharge summary. Conclusions Interns displayed wide variation in the process of creating progress notes. Additional studies are being conducted to determine the impact EHR-based simulation has on standardization of note content.",
author = "March, {Christopher A.} and Gretchen Scholl and Dversdal, {Renee K.} and Matthew Richards and Wilson, {Leah M.} and Vishnu Mohan and Gold, {Jeffrey (Jeff)}",
year = "2016",
month = "5",
day = "1",
doi = "10.4300/JGME-D-15-00201.1",
language = "English (US)",
volume = "8",
pages = "237--240",
journal = "Journal of graduate medical education",
issn = "1949-8349",
publisher = "University of Finance and Management",
number = "2",

}

TY - JOUR

T1 - Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes

AU - March, Christopher A.

AU - Scholl, Gretchen

AU - Dversdal, Renee K.

AU - Richards, Matthew

AU - Wilson, Leah M.

AU - Mohan, Vishnu

AU - Gold, Jeffrey (Jeff)

PY - 2016/5/1

Y1 - 2016/5/1

N2 - Background With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training. Objective To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes. Methods Three months after beginning their internship, 32 interns participated in an EHR simulation designed to assess patterns in note writing and generation. Each intern was given a simulated chart and instructed to create a daily progress note. Notes were graded for use of copy-paste, macros, and accuracy of presented data. Results A total of 31 out of 32 interns (97%) completed the exercise. There was wide variance in use of macros to populate data, with multiple macro types used for the same data category. Three-quarters of notes contained either copy-paste elements or the elimination of active medical problems from the prior days' notes. This was associated with a significant number of quality issues, including failure to recognize a lack of deep vein thrombosis prophylaxis, medications stopped on admission, and issues in prior discharge summary. Conclusions Interns displayed wide variation in the process of creating progress notes. Additional studies are being conducted to determine the impact EHR-based simulation has on standardization of note content.

AB - Background With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training. Objective To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes. Methods Three months after beginning their internship, 32 interns participated in an EHR simulation designed to assess patterns in note writing and generation. Each intern was given a simulated chart and instructed to create a daily progress note. Notes were graded for use of copy-paste, macros, and accuracy of presented data. Results A total of 31 out of 32 interns (97%) completed the exercise. There was wide variance in use of macros to populate data, with multiple macro types used for the same data category. Three-quarters of notes contained either copy-paste elements or the elimination of active medical problems from the prior days' notes. This was associated with a significant number of quality issues, including failure to recognize a lack of deep vein thrombosis prophylaxis, medications stopped on admission, and issues in prior discharge summary. Conclusions Interns displayed wide variation in the process of creating progress notes. Additional studies are being conducted to determine the impact EHR-based simulation has on standardization of note content.

UR - http://www.scopus.com/inward/record.url?scp=85011977886&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85011977886&partnerID=8YFLogxK

U2 - 10.4300/JGME-D-15-00201.1

DO - 10.4300/JGME-D-15-00201.1

M3 - Article

VL - 8

SP - 237

EP - 240

JO - Journal of graduate medical education

JF - Journal of graduate medical education

SN - 1949-8349

IS - 2

ER -