Finding common ground: the road to electronic interprofessional documentation




McDonald, Kristie

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This thesis portrays a research study undertaken to explore the unknown concept of electronic interprofessional documentation. Academic literature largely centers on multidisciplinary electronic documentation yet clinicians provide care using an integrated interprofessional model. Current design of electronic health records (EHRs) continue to propagate a deluge of data resulting from disparate siloed documentation. End users report challenges with finding data. Additionally, care planning and decision making are delayed. To bridge the gap between electronic design and interprofessional delivery of care, more understanding of shared documentation is required. The provenance of the design of this study is based on the concept of common ground and the framework for complex diverse data. Common ground is a shared communication space within a team with a shared purpose (Cioffi, Wilkes, Cummings, Warne, & Harrison, 2010). The framework for complex diverse data posits that data must be linked to other interconnected data; linked data enables connection of diverse pieces and insight-sharing within a team. A descriptive qualitative study was designed to answer the research question: What are the common data elements between disciplines? A case scenario of a patient with a fractured hip was created; participants generated clinical notes based on the video and patient record. The clinical notes were coded and results indicated numerous diverse common data elements. These were analyzed and major findings such as categories appropriate for use by all disciplines on admission and design implications for care planning throughout an acute care stay were identified. Further, as disciplines and care team members do have different documentation patterns, it is suggested attendance to differences in the entry of data yet maintaining a common ground in the display of patient information is vital. Finally suggestions such as duplicate checking for documentation through a common care plan that tracks assessments and completed interventions alongside planned interventions are made. Creation of a standardized interprofessional terminology is key in building the road leading to interprofessional electronic documentation.



Interprofessional electronic documentation, electronic health record, EHR, Interprofessional care, Common Ground, Standardized Interprofessional Terminology, Descriptive Qualitative Research