Physician use of a computerized medical record system during the patient encounter: a descriptive study

• HIT Description: A home-grown computerized medical record program More info...
  
• Purpose of Study: Investigate physician use of and interaction with a direct-entry computerized medical record system
  
• Years of study: Not Available
  
• Study Design: Quantitative descriptive
  
• Outcomes: Total encounter time, record use
  

• Settings: The pediatric department of the Ofakim primary care community clinic, Israel
• Intervention: Introduction of CLINIC computer system.
• Evaluation Method: Video-recorded encounters of four physicians before and after installation of the computer, including 77 without computer and 55 with computer.
• Description: A computerized medical record system called CLINIC. Faculty at Ben-Gurion University of the Negev, Israel, developed the system to be used directly by primary care professionals in primary care clinics. The system had been in use for over 6 years at the time of the study.
• Extrinsic Factors in valuing cost and benefits: Prior to computerization of the medical record, medical information was kept in paper-based records.
• Changes in efficiency and productivity: The total mean encounter time was similar with or without the computer, but the lengths of the encounter components and record use did change. The physicians increased the proportion of encounter time spent in documentation and decreased the proportion spent in record review. The physicians work style changed from simultaneous recording on paper and talking with patients to interval recording between talking and using the computer.