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Title page for ETD etd-11262012-114245

Type of Document Master's Thesis
Author Khan, Naqi Ali
Author's Email Address naqi.khan@vanderbilt.edu
URN etd-11262012-114245
Title Clinical Encounter Information Flow: Applications In Evaluating Medical Documentation Tools
Degree Master of Science
Department Biomedical Informatics
Advisory Committee
Advisor Name Title
Dr. S. Trent Rosenbloom Committee Chair
Dr. Joshua C. Denny Committee Member
Dr. Kevin B. Johnson Committee Member
Dr. Qingxia Chen Committee Member
  • clinical simulation semantic similarity snomed snomed-ct evaluation systems biomedical informatics
Date of Defense 2012-10-15
Availability unrestricted
There is little research on how clinically relevant concepts are transferred from a patient, through a healthcare provider, and then to a resultant clinical note. This study tested whether clinical information flow, defined as the transfer of concepts from patient to note, can be traced. The study's investigators also analyzed the impact of a clinical documentation tool on note content.

Healthcare providers, designated as clinical simulation study subjects, generated clinical notes via two documentation tools. The simulation utilized standardized patient scenario descriptions (PSDs). Independent physician reviewers identified clinical concepts present in the PSDs and in resultant clinic notes. Reviewers identified a total of 256 unique clinical concepts across all PSDs. Of these, a total of 122 unique concepts overlapped for the PSDs and resultant notes from both documentation tools. Additionally, the dictation-based and computer-based notes shared 103 distinct concepts not found in the PSDs.

This study's findings suggest that both computer-based and dictation-based tools are subject to clinical concept loss. Templates may have eased documentation, partly explaining the greater concept count for computer-based notes. This study found that tracing information flow in a clinical simulation encounter is a valid method for evaluating medical documentation tools. Clinical note template availability also likely impacts healthcare provider documentation.

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