Interdisciplinary Documentation of Health Care in The Electronic Health Record (EHR): Exploring Information Flow and Overlap

Background: EHR challenges to redesign health delivery systems in order to contribute to health care delivery that is safe, patient-centered, timely, efficient and equitable. The purpose of this work is to investigate one of the significant issues related to the introduction of EHR: Interdisciplinary perspectives on information flow and overlap in documentation by nurses and physicians. Problem statement: Significant problems in terms of information redundancy, timely access to patient information and interdisciplinary utilization of patient data pose challenges to improvement of quality aspects of care. The interdisciplinary documentation perspective and the actual presence of information overlap in the charted notes have not been sufficiently examined in the EHR. Lack of timely access to information and increasingly ineffective communication are core generators of clinical errors. Approach: A new instrument measuring information overlap was developed based on legislation, professional requirements, review of EHRs and applicable instruments. The sample for the instrument refinement process was 50 sets of nurses’ and physicians’ admission and discharge summaries drawn from Norwegian orthopedic EHRs in 2005. Information flow in terms of accessibility of the charted notes was measured by time delay. Results: The final instrument (B-HIOS) after refinement consists of seven items in the admission note and six items in the discharge summary. The information overlap between nurses’ and physicians’ is substantial. Items preferably documented by nurses are pain, while physicians preferably document medication, diagnosis and treatment plan. Nurses’ admission note is accessible on average 4.8 hours earlier than the physicians’ admission note, and the nurses’ discharge summary is available on average 9 hours earlier than the physicians’ discharge summary. Conclusions: The modified kappa method is appropriate for measuring rater agreement of non-diagnostic scales. The identified common items should be utilized as a resource to develop shared documents in the EHR, as it can contribute towards interdisciplinary documentation and a common problem-based conceptual model in the EHR supporting interdisciplinary information flow. There is a noteworthy time delay in availability of the nurses’ and physicians’ note which is a serious threat to the quality of care by inhibiting information flow in the continuum of care