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Documentation of hospitalization risk factors in electronic health records (EHRs): a qualitative study with home healthcare clinicians

Documentation of hospitalization risk factors in electronic health records (EHRs): a qualitative... ObjectiveTo identify the risk factors home healthcare (HHC) clinicians associate with patient deterioration and understand how clinicians respond to and document these risk factors.MethodsWe interviewed multidisciplinary HHC clinicians from January to March of 2021. Risk factors were mapped to standardized terminologies (eg, Omaha System). We used directed content analysis to identify risk factors for deterioration. We used inductive thematic analysis to understand HHC clinicians’ response to risk factors and documentation of risk factors.ResultsFifteen HHC clinicians identified a total of 79 risk factors that were mapped to standardized terminologies. HHC clinicians most frequently responded to risk factors by communicating with the prescribing provider (86.7% of clinicians) or following up with patients and caregivers (86.7%). HHC clinicians stated that a majority of risk factors can be found in clinical notes (ie, care coordination (53.3%) or visit (46.7%)).DiscussionClinicians acknowledged that social factors play a role in deterioration risk; but these factors are infrequently studied in HHC. While a majority of risk factors were represented in the Omaha System, additional terminologies are needed to comprehensively capture risk. Since most risk factors are documented in clinical notes, methods such as natural language processing are needed to extract them.ConclusionThis study engaged clinicians to understand risk for deterioration during HHC. The results of our study support the development of an early warning system by providing a comprehensive list of risk factors grounded in clinician expertize and mapped to standardized terminologies. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the American Medical Informatics Association Oxford University Press

Documentation of hospitalization risk factors in electronic health records (EHRs): a qualitative study with home healthcare clinicians

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References (35)

Publisher
Oxford University Press
Copyright
© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com
ISSN
1067-5027
eISSN
1527-974X
DOI
10.1093/jamia/ocac023
Publisher site
See Article on Publisher Site

Abstract

ObjectiveTo identify the risk factors home healthcare (HHC) clinicians associate with patient deterioration and understand how clinicians respond to and document these risk factors.MethodsWe interviewed multidisciplinary HHC clinicians from January to March of 2021. Risk factors were mapped to standardized terminologies (eg, Omaha System). We used directed content analysis to identify risk factors for deterioration. We used inductive thematic analysis to understand HHC clinicians’ response to risk factors and documentation of risk factors.ResultsFifteen HHC clinicians identified a total of 79 risk factors that were mapped to standardized terminologies. HHC clinicians most frequently responded to risk factors by communicating with the prescribing provider (86.7% of clinicians) or following up with patients and caregivers (86.7%). HHC clinicians stated that a majority of risk factors can be found in clinical notes (ie, care coordination (53.3%) or visit (46.7%)).DiscussionClinicians acknowledged that social factors play a role in deterioration risk; but these factors are infrequently studied in HHC. While a majority of risk factors were represented in the Omaha System, additional terminologies are needed to comprehensively capture risk. Since most risk factors are documented in clinical notes, methods such as natural language processing are needed to extract them.ConclusionThis study engaged clinicians to understand risk for deterioration during HHC. The results of our study support the development of an early warning system by providing a comprehensive list of risk factors grounded in clinician expertize and mapped to standardized terminologies.

Journal

Journal of the American Medical Informatics AssociationOxford University Press

Published: Feb 23, 2022

Keywords: home health; qualitative; electronic health record; Omaha System; nursing informatics; natural language processing

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