Computer-based documentation: effect on parent and physician satisfaction during a pediatric health maintenance encounter

• HIT Description: Electronic health record More info...
  
• Purpose of Study: To assess the impact of a computer-based documentation (CBD) tool on parent and physician satisfaction with a pediatric health maintenance encounter
  
• Years of study: Not Available
  
• Study Design: Pre-post
  
• Outcomes: Impact on patient satisfaction
  

• Settings: Urban hospital-based pediatric teaching clinic; patients were under 18 months of age
• Intervention: Compared parent and provider satisfaction with clinical encounters with and without the use of computer-based documentation. Also assessed provider satisfaction with CBD.
• Evaluation Method: Audio-taped visits, questionnaires to assess satisfaction with the encounters, exit interview for physicians using CBD.
• Description: A noncommercial software program developed by the authors, called Clictate, allows a combination of free-text data input and Òpoint and clickÓ input to create a visit summary. Templates were derived from the American Academy of Pediatrics health maintenance guidelines for 12 specific ages.
• Barriers: Computers were placed on the desktop between the parent and the MD and could not be moved; not measured Ð in discussion
• Quality of Care and Patient Safety Outcome: Neither parent nor physician satisfaction changed significantly with the introduction of CBD. There was significant increase in the percentage of parents who strongly agreed that they were encouraged by their physician to talk about worries.
• Changes in efficiency and productivity: The mean CBD visit length was 32 minutes, compared to 28 minutes with paper forms (p.001). With CBD, 74% of MDs documented physical exam findings, assessment notes, and treatment plans after completing the encounter rather than during it.