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Study practices included two urban teaching practices where fewer than 35% of patients have private insurance as well as 10 suburban practices, not involved in resident teaching, where over 80% of children are privately insured.
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PeRC includes 153 clinicians who work at 31 different practice locations. This study was conducted at 12 practices within The Children's Hospital of Philadelphia (CHOP) Pediatric Research Consortium (PeRC), a multi-state, hospital-owned, primary care practice-based research network caring for more than 235 000 children and adolescents. Extending prior work in the field, we also used statistical models to examine how clinician, patient, and visit characteristics impact both doctor–patient interaction and visit length. We focused on detailing how clinicians with EMR experience integrate the EMR into the visit flow during each component of the clinical encounter. 21 22 Through direct observation, we characterized patterns of EMR use in busy primary care settings and their association with visit length and doctor–patient interaction. In this study, we filled these knowledge gaps by focusing on problem-oriented pediatric acute visits where efficiency is a priority and medical decisions and deliberation are common between the clinician and family. 20 Although prior research has demonstrated that the effective use of clinical decision support systems (CDSS) depends upon understanding clinician workflows, 5 20 these workflows and their variation across primary care clinicians has not been well-characterized. Finally, a fundamental advantage of the EMR over paper-based systems is the ability to deliver clinical decision support to the point of care to promote evidence-based decision making.
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15 17–19 Limited evidence currently exists to guide efforts to help clinician users improve efficiency after they begin using the EMR, an increasingly important demand in practice. Results from studies examining the impact of EMR implementation on visit length have been mixed, with results ranging from no change in visit length to an increase of 5 min. 16 Patterns of use of the EMR at each stage of the clinical encounter and how they differ based on clinician and patient characteristics have not been well-defined. Prior research studies that have examined how EMRs affect doctor–patient communication have been limited by a reliance on surveys or interviews, 10 11 small sample sizes (<10 clinicians), 12–14 a focus on trainees, 15 or limited scope. 7 8Įlucidating patterns of doctor–patient communication and documentation in the setting of visits using the EMR is a necessary first step for promoting the safe and efficient use of these systems. 7–9 In this context, the Agency for Healthcare Research and Quality (AHRQ), National Institute of Standards and Technology (NIST), and the Office of the National Coordinator (ONC) have prioritized efforts to measure and enhance EMR usability.
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3 4 While this investment has the potential to increase the efficiency, coordination, and quality of healthcare, 5 6 recent findings underscore the need for additional research on the usability of these systems in order to achieve better outcomes. 1 2 These ARRA funds will likely increase the use of EMRs by office-based practices from current rates near 20%. As a central feature of efforts to reform the health system, the American Recovery and Reinvestment Act (ARRA) of 2009 allocated $19 billion to promote the adoption of electronic medical records (EMRs).