Informatics Research Seminar: Comparison of Documentation Models Used by Emergency Physicians in a Community Hospital Setting

September 23 @ 4:00 – 5:00 pm

 

Speaker: Guyla Evans, PhD
Presented from ECU

Broadcast Link: Seminar

 

Abstract:

Physician notes are a unique genre within a larger genre ecology of a hospital’s emergency care department. As such, they mediate activities of medical care and may also be appropriated for other uses such as billing and representing the patient’s identity for patient-centered care. These additional uses may exert pressure upon the genre/genre ecology and contribute to its evolution. This study examines four documentation models used at different times over a twenty-year period at a community hospital and describes some of the changes to the genre of the physician’s note along with the concurrent changes to the tools used to produce it. the study results demonstrate how the use of the genre for billing purposes has resulted in an increase in the number documented elements that pertain to billing and coding practices; it further demonstrates that there is considerable variability among the models in terms of how physician documentation reflects the elements of patient-centered care, which include patient needs, preferences, and values; coordination and integration of care; information, education, and communication needs; physical comfort; emotional support; and involving family and friends in care. The study findings suggest that there is an opportunity to improve patient-centeredness as represented within the genre of the physician’s note. Tools within the genre ecology to which the physician’s note belongs have the power to facilitate the conversations that both physician’s note. Tools within the genre ecology to which the physician’s note belongs have the power to facilitate the conversations that both physicians and patient believe are important, thereby increasing the degree of patient-centeredness within the activity system of patient care. Technical and professional communicators are uniquely equipped to contribute their knowledge of genre and genre ecologies when electronic medical record system design and configuration decisions are being made in order to help assure that the genres used in health care lead to actions that benefit patients and practitioners.

Biosketch:

Dr. Guyla Evans is an experienced health informatics professional with over twenty years’ experience in implementing and maintaining electronic health record (EHR) systems in the community hospital environment.  She comes to the field of health informatics as an “accidental analyst,” having migrated to information systems from the clinical laboratory when her employer installed its first integrated EHR system in the early 1990’s.  While completing her doctoral studies, Evans drew upon her deep EHR system experience to select an area of research.  Her interests are in the ways in which documentation created by one professional group is appropriated for use by another, ways that the tools provided by EHR systems shape the documentation created by health professionals, and the ways in which those created documents support various aspects of hospital operations, including billing and patient-centered care.

Dr. Evans holds a BSMT in Medical Technology, an MAEd in Adult Education, a graduate certificate in Health Informatics, and a PhD in Rhetoric, Writing, and Professional Communication.  Her professional certifications include the MT(ASCP)CM (Medical Laboratory Scientist) and SC(ASCP)CM (Specialist in Chemistry) designations.  She currently serves as part-time faculty for East Carolina University and Edgecombe Community College.