Publications by authors named "Adam Rule"

13 Publications

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Comparing Scribed and Non-scribed Outpatient Progress Notes.

AMIA Annu Symp Proc 2021 21;2021:1059-1068. Epub 2022 Feb 21.

Oregon Health & Science University, Portland, OR.

Working with scribes can reduce provider documentation time, but few studies have examined how scribes affect clinical notes. In this retrospective cross-sectional study, we examine over 50,000 outpatient progress notes written with and without scribe assistance by 70 providers across 27 specialties in 2017-2018. We find scribed notes were consistently longer than those written without scribe assistance, with most additional text coming from note templates. Scribed notes were also more likely to contain certain templated lists, such as the patient's medications or past medical history. However, there was significant variation in how working with scribes affected a provider's mix of typed, templated, and copied note text, suggesting providers adapt their documentation workflows to varying degrees when working with scribes. These results suggest working with scribes may contribute to note bloat, but that providers' individual documentation workflows, including their note templates, may have a large impact on scribed note contents.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8861667PMC
April 2022

Clinical Documentation During Scribed and Non-scribed Ophthalmology Office Visits.

Ophthalmol Sci 2021 Dec 6;1(4). Epub 2021 Dec 6.

Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon.

Purpose: Observe the impact of employing scribes on documentation efficiency in ophthalmology clinics.

Design: Single-center retrospective cohort study.

Participants: A total of 29,997 outpatient visits conducted by seven attending ophthalmologists between 1/1/2018 and 12/31/2019 were included in the study; 18,483 with a scribe present during the encounter and 11,514 without a scribe present.

Intervention: Use of a scribe.

Main Outcome Measures: Total physician documentation time, physician documentation time during and after the visit, visit length, time to chart closure, note length, and percent of note text edited by physician.

Results: Total physician documentation time was significantly less when working with a scribe (mean ± SD, 4.7 ± 2.9 vs. 7.6 ± 3.8 minutes/note, <.001), as was documentation time during the visit (2.8 ± 2.2 vs. 5.9 ± 3.1 minutes/note, <.001). Physicians also edited scribed notes less, deleting 1.9 ± 4.4% of scribes' draft note text and adding 14.8 ± 11.4% of the final note text, compared to deleting 6.0 ± 9.1%(<.001) of draft note text and adding 21.2 ± 15.3%(<.001) of final note text when not working with a scribe. However, physician after-visit documentation time was significantly higher with a scribe for 3 of 7 physicians (<.001). Scribe use was also associated with an office visit length increase of 2.9 minutes (<.001) per patient and time to chart closure of 3.0 hours (<.001), according to mixed-effects linear models.

Conclusions: Scribe use was associated with increased documentation efficiency through lower total documentation time and less note editing by physicians. However, the use of a scribe was also associated with longer office visit lengths and time to chart closure. The variability in the impact of scribe use on different measures of documentation efficiency leaves unanswered questions about best practices for the implementation of scribes, and warrants further study of effective scribe use.
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http://dx.doi.org/10.1016/j.xops.2021.100088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8765735PMC
December 2021

Frequent but fragmented: use of note templates to document outpatient visits at an academic health center.

J Am Med Inform Assoc 2021 12;29(1):137-141

Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA.

Recent changes to billing policy have reduced documentation requirements for outpatient notes, providing an opportunity to rethink documentation workflows. While many providers use templates to write notes-whether to insert short phrases or draft entire notes-we know surprisingly little about how these templates are used in practice. In this retrospective cross-sectional study, we observed the templates that primary providers and other members of the care team used to write the provider progress note for 2.5 million outpatient visits across 52 specialties at an academic health center between 2018 and 2020. Templates were used to document 89% of visits, with a median of 2 used per visit. Only 17% of the 100 230 unique templates were ever used by more than one person and most providers had their own full-note templates. These findings suggest template use is frequent but fragmented, complicating template revision and maintenance. Reframing template use as a form of computer programming suggests ways to maintain the benefits of personalization while leveraging standardization to reduce documentation burden.
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http://dx.doi.org/10.1093/jamia/ocab230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8714279PMC
December 2021

Electronic health record note review in an outpatient specialty clinic: who is looking?

JAMIA Open 2021 Jul 31;4(3):ooab044. Epub 2021 Jul 31.

National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA.

Note entry and review in electronic health records (EHRs) are time-consuming. While some clinics have adopted team-based models of note entry, how these models have impacted note review is unknown in outpatient specialty clinics such as ophthalmology. We hypothesized that ophthalmologists and ancillary staff review very few notes. Using audit log data from 9775 follow-up office visits in an academic ophthalmology clinic, we found ophthalmologists reviewed a median of 1 note per visit (2.6 ± 5.3% of available notes), while ancillary staff reviewed a median of 2 notes per visit (4.1 ± 6.2% of available notes). While prior ophthalmic office visit notes were the most frequently reviewed note type, ophthalmologists and staff reviewed no such notes in 51% and 31% of visits, respectively. These results highlight the collaborative nature of note review and raise concerns about how cumbersome EHR designs affect efficient note review and the utility of prior notes in ophthalmic clinical care.
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http://dx.doi.org/10.1093/jamiaopen/ooab044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325486PMC
July 2021

Length and Redundancy of Outpatient Progress Notes Across a Decade at an Academic Medical Center.

JAMA Netw Open 2021 07 1;4(7):e2115334. Epub 2021 Jul 1.

Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland.

Importance: There is widespread concern that clinical notes have grown longer and less informative over the past decade. Addressing these concerns requires a better understanding of the magnitude, scope, and potential causes of increased note length and redundancy.

Objective: To measure changes between 2009 and 2018 in the length and redundancy of outpatient progress notes across multiple medical specialties and investigate how these measures associate with author experience and method of note entry.

Design, Setting, And Participants: This cross-sectional study was conducted at Oregon Health & Science University, a large academic medical center. Participants included clinicians and staff who wrote outpatient progress notes between 2009 and 2018 for a random sample of 200 000 patients. Statistical analysis was performed from March to August 2020.

Exposures: Use of a comprehensive electronic health record to document patient care.

Main Outcomes And Measures: Note length, note redundancy (ie, the proportion of text identical to the patient's last note), and percentage of templated, copied, or directly typed note text.

Results: A total of 2 704 800 notes written by 6228 primary authors across 46 specialties were included in this study. Median note length increased 60.1% (99% CI, 46.7%-75.2%) from a median of 401 words (interquartile range [IQR], 225-660 words) in 2009 to 642 words (IQR, 399-1007 words) in 2018. Median note redundancy increased 10.9 percentage points (99% CI, 7.5-14.3 percentage points) from 47.9% in 2009 to 58.8% in 2018. Notes written in 2018 had a mean value of just 29.4% (99% CI, 28.2%-30.7%) directly typed text with the remaining 70.6% of text being templated or copied. Mixed-effect linear models found that notes with higher proportions of templated or copied text were significantly longer and more redundant (eg, in the 2-year model, each 1% increase in the proportion of copied or templated note text was associated with 1.5% [95% CI, 1.5%-1.5%] and 1.6% [95% CI, 1.6%-1.6%] increases in note length, respectively). Residents and fellows also wrote significantly (26.3% [95% CI, 25.8%-26.7%]) longer notes than more senior authors, as did more recent hires (1.8% for each year later [95% CI, 1.3%-2.4%]).

Conclusions And Relevance: In this study, outpatient progress notes grew longer and more redundant over time, potentially limiting their use in patient care. Interventions aimed at reducing outpatient progress note length and redundancy may need to simultaneously address multiple factors such as note template design and training for both new and established clinicians.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.15334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8290305PMC
July 2021

Methods for Large-Scale Quantitative Analysis of Scribe Impacts on Clinical Documentation.

AMIA Annu Symp Proc 2020 25;2020:573-582. Epub 2021 Jan 25.

Department of Medical Informatics and Clinical Epidemiology.

Many medical providers employ scribes to manage electronic health record (EHR) documentation. Prior studies have shown the benefits of scribes, but no large-scale study has quantitively assessed scribe impact on documentation workflows. We propose methods that leverage EHR data for identifying scribe presence during an office visit, measuring provider documentation time, and determining how notes are edited and composed. In a case study, we found scribe use was associated with less provider documentation time overall (averaging 2.4 minutes or 39% less time, p < 0.001), fewer note edits by providers (8.4% less added and 4.2% less deleted text, p < 0.001), but significantly more documentation time after the visit for four out of seven providers (p < 0.001) and no change in the amount of copied and imported note text. Our methods could validate prior study results, identify variability for determining best practices, and determine that scribes do not improve all aspects of documentation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075531PMC
June 2021

Clinical Documentation as End-User Programming.

Proc SIGCHI Conf Hum Factor Comput Syst 2020 Apr;2020

Medical Informatics & Clinical Epidemiology, Oregon Health & Science University.

As healthcare providers have transitioned from paper to electronic health records they have gained access to increasingly sophisticated documentation aids such as custom note templates. However, little is known about how providers use these aids. To address this gap, we examine how 48 ophthalmologists and their staff create and use - a customizable and composable form of note template - to document office visits across two years. In this case study, we find 1) content-importing phrases were used to document the vast majority of visits (95%), 2) most content imported by these phrases was structured data imported by data-links rather than boilerplate text, and 3) providers primarily used phrases they had created while staff largely used phrases created by other people. We conclude by discussing how framing clinical documentation as end-user programming can inform the design of electronic health records and other documentation systems mixing data and narrative text.
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http://dx.doi.org/10.1145/3313831.3376205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901830PMC
April 2020

Metrics for assessing physician activity using electronic health record log data.

J Am Med Inform Assoc 2020 04;27(4):639-643

Department of Medical Informatics and Clinical Epidemiology, Oregon Health Sciences University, Oregon, USA.

Electronic health record (EHR) log data have shown promise in measuring physician time spent on clinical activities, contributing to deeper understanding and further optimization of the clinical environment. In this article, we propose 7 core measures of EHR use that reflect multiple dimensions of practice efficiency: total EHR time, work outside of work, time on documentation, time on prescriptions, inbox time, teamwork for orders, and an aspirational measure for the amount of undivided attention patients receive from their physicians during an encounter, undivided attention. We also illustrate sample use cases for these measures for multiple stakeholders. Finally, standardization of EHR log data measure specifications, as outlined here, will foster cross-study synthesis and comparative research.
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http://dx.doi.org/10.1093/jamia/ocz223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075531PMC
April 2020

Electronic Health Records in Ophthalmology: Source and Method of Documentation.

Am J Ophthalmol 2020 03 5;211:191-199. Epub 2019 Dec 5.

Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA. Electronic address:

Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes.

Design: EHR documentation review and analysis.

Methods: Setting: a single academic ophthalmology department.

Study Population: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation.

Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes.

Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.
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http://dx.doi.org/10.1016/j.ajo.2019.11.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073273PMC
March 2020

Using electronic health record audit logs to study clinical activity: a systematic review of aims, measures, and methods.

J Am Med Inform Assoc 2020 03;27(3):480-490

Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA.

Objective: To systematically review published literature and identify consistency and variation in the aims, measures, and methods of studies using electronic health record (EHR) audit logs to observe clinical activities.

Materials And Methods: In July 2019, we searched PubMed for articles using EHR audit logs to study clinical activities. We coded and clustered the aims, measures, and methods of each article into recurring categories. We likewise extracted and summarized the methods used to validate measures derived from audit logs and limitations discussed of using audit logs for research.

Results: Eighty-five articles met inclusion criteria. Study aims included examining EHR use, care team dynamics, and clinical workflows. Studies employed 6 key audit log measures: counts of actions captured by audit logs (eg, problem list viewed), counts of higher-level activities imputed by researchers (eg, chart review), activity durations, activity sequences, activity clusters, and EHR user networks. Methods used to preprocess audit logs varied, including how authors filtered extraneous actions, mapped actions to higher-level activities, and interpreted repeated actions or gaps in activity. Nineteen studies validated results (22%), but only 9 (11%) through direct observation, demonstrating varying levels of measure accuracy.

Discussion: While originally designed to aid access control, EHR audit logs have been used to observe diverse clinical activities. However, most studies lack sufficient discussion of measure definition, calculation, and validation to support replication, comparison, and cross-study synthesis.

Conclusion: EHR audit logs have potential to scale observational research but the complexity of audit log measures necessitates greater methodological transparency and validated standards.
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http://dx.doi.org/10.1093/jamia/ocz196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025338PMC
March 2020

Redundancy of Progress Notes for Serial Office Visits.

Ophthalmology 2020 01 21;127(1):134-135. Epub 2019 Jun 21.

Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon.

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http://dx.doi.org/10.1016/j.ophtha.2019.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6925342PMC
January 2020

Ten simple rules for writing and sharing computational analyses in Jupyter Notebooks.

PLoS Comput Biol 2019 07 25;15(7):e1007007. Epub 2019 Jul 25.

Data Science Hub, San Diego Supercomputer Center, UC San Diego, La Jolla, California, United States of America.

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http://dx.doi.org/10.1371/journal.pcbi.1007007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657818PMC
July 2019

Validating free-text order entry for a note-centric EHR.

AMIA Annu Symp Proc 2015 5;2015:1103-10. Epub 2015 Nov 5.

UC San Diego, La Jolla, CA; West Health, La Jolla, CA.

Electronic Health Records (EHRs) have increased the utility and portability of health information by storing it in structured formats. However, EHRs separate this structured data from the rich, free-text descriptions of clinical notes. The ultimate objective of our research is to develop an interactive progress note that unifies entry, access, and retrieval of structured and unstructured health information. In this study we present the design and subsequent testing with eight clinicians of a core element of this envisioned note: free-text order entry. Clinicians saw this new order-entry paradigm as a way to save time and preserve data quality by reducing double-documentation. However, they wanted the prototype to recognize more diverse types of shorthand and apply default values to fields that remain fairly constant across orders, such as number of refills and pickup location. Future work will test more complex orders, such as cascading orders, with a broader range of clinicians.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765684PMC
April 2018
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