A hospital-wide transition from paper to digital problem-oriented clinical notes. A descriptive history and cross-sectional survey of use, usability, and satisfaction.

OBJECTIVES: To evaluate the use, usability, and physician satisfaction of a locally developed problem-oriented clinical notes application that replaced paper-based records in a large Dutch university medical center. METHODS: Using a clinical notes database and an application event log file and a cross-sectional survey of usability, authors retrospectively analyzed system usage for medical specialties, users, and patients over 4 years. A standardized questionnaire measured usability. Authors analyzed the effects of sex, age, professional experience, training hours, and medical specialty on user satisfaction via univariate analysis of variance. Authors also examined the correlation between user satisfaction in relation to users' intensity of use of the application. RESULTS: In total 1,793 physicians used the application to record progress notes for 219,755 patients. The overall satisfaction score was 3.2 on a scale from 1 (highly dissatisfied) to 5 (highly satisfied). A statistically significant difference occurred in satisfaction by medical specialty, but no statistically significant differences in satisfaction took place by sex, age, professional experience, or training hours. Intensity of system use did not correlate with physician satisfaction. CONCLUSIONS: By two years after the start of the implementation, all medical specialties utilized the clinical notes application. User satisfaction was neutral (3.2 on a 1-5 scale). Authors believe that the significant factors facilitating this transition mirrored success factors reported by other groups: a generic, consistent, and transparent design of the application; intensive collaboration; continuous monitoring; and an incremental rollout.

Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature.

BACKGROUND: A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR. METHODS: On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements. RESULTS: In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability. CONCLUSIONS: Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.