ActiveNotes: computer-assisted creation of patient progress notes

ABSTRACT

We present activeNotes, a prototype application that supports the creation of Critical Care Notes by physicians in a hospital intensive care unit. activeNotes integrates automated, context-sensitive patient data retrieval and user control of automated data updates and alerts into the note-creation process. In a user study at New York Presbyterian Hospital, we gathered qualitative feedback on the prototype from 15 physicians. The physicians found activeNotes to be valuable and said they would use it to create both formal notes for medical records and informal notes. One surprising finding is that while physicians have rejected template-based clinical documentation systems in the past, they expressed a desire to use activeNotes to create personalized, physician-specific note templates to be reused with a given patient, or for a given condition.

REFERENCES

• 1: Dorrit Billman , Eric A. Bier, Medical sensemaking with entity workspace, Proceedings of the SIGCHI conference on Human factors in computing systems, April 28-May 03, 2007, San Jose, California, USA [doi>10.1145/1240624.1240662]
• 2: Eclipsys. http://www.eclipsys.com/
• 3: Haas, J., Bright, T., Bakken, S., Stetson, P., Johnson, S. Clinician perceptions of the usability of eNote. Proc AMIA Symp. 2005, 973.
• 4: 4Hripcsak, G., Cimino, J., and Sengupta, S. WebCIS: Large scale deployment of a Web-based clinical information system. Proc. Amer. Med. Informatics Assoc. Symp., 1999, 804--808.
• 5: Gary Hsieh , Jennifer Lai , Scott E. Hudson , Robert Kraut, Using tags to assist near-synchronous communication, Proceeding of the twenty-sixth annual SIGCHI conference on Human factors in computing systems, April 05-10, 2008, Florence, Italy [doi>10.1145/1357054.1357093]
• 6: Gareth Hughes , Leslie Carr, Microsoft smart tags: support, ignore or condemn them?, Proceedings of the thirteenth ACM conference on Hypertext and hypermedia, June 11-15, 2002, College Park, Maryland, USA [doi>10.1145/513338.513362]
• 7: Sameer Malhotra , Desmond Jordan , Edward Shortliffe , Vimla L. Patel, Workflow modeling in critical care: Piecing together your own puzzle, Journal of Biomedical Informatics, v.40 n.2, p.81-92, April, 2007 [doi>10.1016/j.jbi.2006.06.002]
• 8: Miller, R.H., Sim, I. Physicians use of electronic medical records: Barriers and solutions. Health Affairs.
• 9: Muller, M. Patterns of tag usage across four diverse enterprise tagging services. Proc. HCIC 2007.
• 10: Theodor Holm Nelson, The heart of connection: hypermedia unified by transclusion, Communications of the ACM, v.38 n.8, p.31-33, Aug. 1995 [doi>10.1145/208344.208353]
• 11: Rosenbloom, S., Grande, J., Geissbuhler, A., and Miller, R. Experience in Implementing Inpatient Clinical Note Capture via a Provider Order Entry System. J Am Med Inform Assoc., 2004, Jul-Aug, 11(4), 310--315.
• 12: Tang, PH (ed). Key capabilities of an electronic health record system. Washington DC: Institute of Medicine, National Academy Press, 2003.
• 13: VISICU eICU eCareManager. http://visicu.com/products/evantagesystem.html
• 14: WebCIS. https://webcis.cpmc.columbia.edu/webcis/
• 15: Weir, C., Hurdle, J., Felgar, M., Hoffman, J., Roth, B., Nebeker, J. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42(1):61--7.
• 16: Michelle X. Zhou , Keith Houck , Shimei Pan , James Shaw , Vikram Aggarwal , Zhen Wen, Enabling context-sensitive information seeking, Proceedings of the 11th international conference on Intelligent user interfaces, January 29-February 01, 2006, Sydney, Australia [doi>10.1145/1111449.1111479]

INDEX TERMS

Primary Classification:
  H. Information Systems
  H.5 INFORMATION INTERFACES AND PRESENTATION (I.7)
      H.5.2 User Interfaces (D.2.2, H.1.2, I.3.6)
          Subjects: Graphical user interfaces (GUI)

Additional Classification:
  H. Information Systems
  H.5 INFORMATION INTERFACES AND PRESENTATION (I.7)
      H.5.2 User Interfaces (D.2.2, H.1.2, I.3.6)
          Subjects: Prototyping; User-centered design

General Terms:
Human Factors

Keywords:
evaluation, interaction techniques, interactive systems, medical user interfaces