ArticleJournal of the American Medical Informatics Association : JAMIA
Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators.
Article in Journal of the American Medical Informatics Association : JAMIA. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 30 papers, 3 of them syntheses that pooled it.
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Who cites it
30 citing papers in PubMed, 3 syntheses or guidelines pooled it.
- The impact of eHealth use on general practice workload in the pre-COVID-19 era: a systematic review.BMC health services research · 2024Pooled it
- The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals-A Systematic Review.Journal of medical systems · 2022Pooled it
- Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature.Journal of medical Internet research · 2018Pooled it
- An electronic documentation system improves the quality of admission notes: a randomized trial.Journal of the American Medical Informatics Association : JAMIA · 2017Trial
- Evaluating clinical AI summaries with large language models as judges.NPJ digital medicine · 2025Article
- Development and validation of the provider documentation summarization quality instrument for large language models.Journal of the American Medical Informatics Association : JAMIA · 2025Article
- Automating Evaluation of AI Text Generation in Healthcare with a Large Language Model (LLM)-as-a-Judge.medRxiv : the preprint server for health sciences · 2025Article
- Call me Dr Ishmael: trends in electronic health record notes available at emergency department visits and admissions.JAMIA open · 2024Article
- The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis.JMIR medical informatics · 2024Article
- Aci-bench: a Novel Ambient Clinical Intelligence Dataset for Benchmarking Automatic Visit Note Generation.Scientific data · 2023Article
- Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians.Southern medical journal · 2023Article
- A cross-sectional retrospective study comparing handwritten operation notes with electronic operation notes.Annals of the Royal College of Surgeons of England · 2023Article
- The SHOnet learning health system: Infrastructure for continuous learning in pediatric rehabilitation.Learning health systems · 2022Article
- Through the Narrative Looking Glass: Commentary on "Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review".Journal of medical Internet research · 2022Article
- Feeling and thinking: can theories of human motivation explain how EHR design impacts clinician burnout?Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Adapting Bidirectional Encoder Representations from Transformers (BERT) to Assess Clinical Semantic Textual Similarity: Algorithm Development and Validation Study.JMIR medical informatics · 2021Article
- Assessment of Electronic Health Record Search Patterns and Practices by Practitioners in a Large Integrated Health Care System.JAMA network open · 2020Article
- Words prediction based on N-gram model for free-text entry in electronic health records.Health information science and systems · 2019Article
- Electronic medical record implementation for a healthcare system caring for homeless people.JAMIA open · 2019Article
- The role of medical data in efficient patient care delivery: a review.Risk management and healthcare policy · 2019Review
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveClinical documentation is central to the medical record and so to a range of healthcare and business processes. As electronic health record adoption expands, computerized provider documentation (CPD) is increasingly the primary means of capturing clinical documentation. Previous CPD studies have focused on particular stakeholder groups and sites, often limiting their scope and conclusions. To address this, we studied multiple stakeholder groups from multiple sites across the USA.
methodsWe conducted 14 focus groups at five Department of Veterans Affairs facilities with 129 participants (54 physicians or practitioners, 34 nurses, and 37 administrators). Investigators qualitatively analyzed resultant transcripts, developed categories linked to the data, and identified emergent themes.
resultsFive major themes related to CPD emerged: communication and coordination; control and limitations in expressivity; information availability and reasoning support; workflow alteration and disruption; and trust and confidence concerns. The results highlight that documentation intertwines tightly with clinical and administrative workflow. Perceptions differed between the three stakeholder groups but remained consistent within groups across facilities.
conclusionsCPD has dramatically changed documentation processes, impacting clinical understanding, decision-making, and communication across multiple groups. The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows. Current CPD systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated 'paper-chart' paradigm. These findings should inform those implementing CPD systems now and future plans for more effective CPD systems.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.