Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review

被引:30
作者
Wiebe, Natalie [1 ]
Varela, Lucia Otero [1 ]
Niven, Daniel J. [1 ,2 ]
Ronksley, Paul E. [1 ]
Iragorri, Nicolas [1 ]
Quan, Hude [1 ]
机构
[1] Univ Calgary, Cumming Sch Med, Dept Community Hlth Sci, 3rd Floor TRW Bldg,3280 Hosp Dr NW, Calgary, AB T2N 4Z6, Canada
[2] Univ Calgary, Cumming Sch Med, Dept Crit Care Med, Calgary, AB, Canada
关键词
electronic health records; documentation; quality improvement; inpatient; intervention; CLINICAL-DECISION-SUPPORT; DISCHARGE SUMMARIES; QUALITY; PROGRAM; TIMELINESS; INSTRUMENT; DICTATION; RESIDENTS; FEEDBACK; WORKFLOW;
D O I
10.1093/jamia/ocz081
中图分类号
TP [自动化技术、计算机技术];
学科分类号
0812 ;
摘要
Objective: Despite the widespread and increasing use of electronic health records (EHRs), the quality of EHRs is problematic. Efforts have been made to address reasons for poor EHR documentation quality. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or paper documentation. The purpose of this systematic review was to assess the effectiveness of interventions seeking to improve EHR documentation within an inpatient setting. Materials and Methods: A search strategy was developed based on elaborated inclusion/exclusion criteria. Four databases, gray literature, and reference lists were searched. A REDCap data capture form was used for data extraction, and study quality was assessed using a customized tool. Data were analyzed and synthesized in a narrative, semiquantitative manner. Results: Twenty-four studies were included in this systematic review. Owing to high heterogeneity, quantitative comparison was not possible. However, statistically significant results in interventions and affected outcomes were analyzed and discussed. Education and implementation of a new EHR reporting system were the most successful interventions, as evidenced by significantly improved EHR documentation. Discussion: Heterogeneity of interventions, outcomes, document type, EHR user, and other variables led to difficulty in measuring EHR documentation quality and effectiveness of interventions. However, the use of education as a primary intervention aligned closely with existing literature in similar fields. Conclusions: Interventions implemented to enhance EHR documentation are highly variable and require standardization. Emphasis should be placed on this novel area of research to improve communication between healthcare providers and facilitate data sharing between centers and countries.
引用
收藏
页码:1389 / 1400
页数:12
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