Round Two: A Discussion-based, Follow-up on Computerized Provider Documentation

A discussion-based follow-up to the recent webinar on "Computerized Provider Documentation: Evaluating Implications for Healthcare Practice, Quality and Research," with Trent Rosenbloom, MD, MPH, FACMI, Associate Professor of Biomedical Informatics, and Internal Medicine and Pediatrics at Vanderbilt. Trent will refresh us on his team’s NLM-funded study with 10 minutes of slide presentation, and then we’ll spend the rest of the hour discussing the many areas of interest and participant questions that we couldn’t cover fully the first time, steered by your research work, your clinical experience, your knowledge of the issues and your interests.

Clinical documentation and the problems and informatics challenges surrounding it are at the heart of clinical informatics and many of the systems and human-computer interaction issues we grapple with all the time in our discussions, research and clinical work.

Learning Objectives

Potential topics for discussion include:

• Structure v. flexibility and the levels of expressiveness permitted by various clinical documentation methods.
• Just how inflexibile are your clinical documentation systems? What’s lost? Are there dangers introduced? What are these dangers?
• Note bloat.
• How flexible or proscriptive is your institution in offering documentation options to departments/clinics/individuals? Recent recommendations to ONC based on AMIA policy documentation meeting.
• Usability issues. What evaluation standards do we have for ongoing research & development needs for clinical documentation systems? What usability testing is being conducted for these systems – in research settings? In commercial settings? What is our obligation to close the circuit between research findings and industry? How can researchers partner more with industry? What is the regulatory role in this?
• To what extent does the multiple use of data not create conflicts in documentation? Think about documentation for continuity of care, legal requirements, reimbursement, research? Is it be possible to serve these needs with the same documentation approach?
• Discussion on the qualitative evaluation methods for the components of this clinical documentation evaluation study -- to date and for its ongoing work. What sorts of expertise is required? Who has this expertise within Trent’s team? What sort of qualitative expertise do you have in your institution? Are we building qualitative methods excellence into our biomedical/health informatics programs?

Speaker Information

S. Trent Rosenbloom, MD, MPH, FACMI, Associate Professor of Biomedical Informatics, and Internal Medicine and Pediatrics at Vanderbilt University.

Trent was awarded the AMIA New Investigator Award in 2009. You can read more about some of his many accomplishments here: https://medschool.vanderbilt.edu/dbmi/people/rosenbloom