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Awareness of the Care Team in Electronic Health Records

Journal: Applied Clinical Informatics
ISSN: 1869-0327
DOI: https://doi.org/10.4338/ACI-2011-05-RA-0034
Issue: Vol. 2: Issue 4 2011
Pages: 395-405

Awareness of the Care Team in Electronic Health Records

Research Article

D. K. Vawdrey (1), L. G. Wilcox (2), S. Collins (1), S. Feiner (2), O. Mamykina (1), D. M. Stein (1), S. Bakken (1, 3), M. R. Fred (4), P. D. Stetson (1, 5)

(1) Department of Biomedical Informatics, Columbia University; (2) Department of Computer Science, Columbia University; (3) School of Nursing, Columbia University; (4) Department of Information Systems, New York-Presbyterian Hospital; (5) Department of Medicine, Columbia University, New York, NY

Keywords

patient care team, Electronic health records, Health information technology, Provider communication, care team

Summary

Objective: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients’ care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center.

Methods: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients’ hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called “Care Providers”, and 2) a custom “Designate Provider” order that was created primarily to improve accuracy of the attending physician of record documentation.

Results: For patients with a 3–5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients’ care teams (social workers, dietitians, pharmacists, etc.) was absent.

Conclusions: The two methods for specifying care team information failed to identify numerous individuals involved in patients’ care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.

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