Recorded vignettes: a novel method for investigating documentation in the Electronic Healthcare Record (EHR)

摘要

Background: 360 million consultations documented annually in England1 Accurate descriptors required for secondary data functions: Computerised decision support; Financial reimbursement; Audit; Disease prevalence monitoring and research Coding is not explicitly taught within the GP curriculum How do you research how clinicians document? Previous studies: use real patients2/actors3 interacting with clinician studied; Lack standardisation; Expensive. Why Allergy? Growing clinical problem; 2014 NICE guidelines4: Poor clinical documentation is a major issue in allergy; EHR can’t distinguish between intolerance and allergy; Incorrect labelling of patients; Adverse impact on patient care? Little known about coding practices in non-incentivised condition such as allergy. Method: A novel method developed to standardize research of EHR use. Filmed 6 short vignettes (21-50 secs) Monologue of common allergic presentations as if in consultation with a doctor. Digital photographs were included to replicate rashes. Electronic distribution of study files Documented vignettes in their own EHR Returned screen-prints to the researcher for analysis - Codes, free text and EHR functions Questionnaire - Exploring decision-making and validation of method Initially piloted on 1 GP and 2 trainees leading to refinements. Results 7 GPs and 15 GP trainees were recruited All successfully completed Data was returned from 4 different EHRs SystmOne (6), EmisLV (2), EmisWeb (6) and Vision (8) Screen prints effectively captured data with minor technical difficulties reported by 2 participants The study took 1 - 2 hours to complete: longer than expected from the pilot study.