Breadcrumbs: Assessing the Feasibility of Automating Provider Documentation Using Electronic Health Record Activity

AMIA Annu Symp Proc. 2018 Dec 5:2018:1008-1017. eCollection 2018.

Abstract

This study assessed the feasibility of automating the generation of the outpatient encounter summary. We reviewed screen tracking video and log-file metadata from electronic health record (EHR) interactions based on two simulated encounters. We mapped the sequence of metadata to key concepts in the video to assess the precision with which the log files aligned with user activity and to generate the Breadcrumbs encounter summary (BES). The BES captured all interactions documented in clinical notes with the exception of the physical exam. The videos addressed all Evaluation and Management (E/M) requirements, while the log files did not contain the physical exam. The BES was as comprehensive as the gold standard visit summary. The BES offers a promising method for the collection and compilation of necessary elements of outpatient clinical documentation. The combination of log files and video could provide evidence of EHR activity satisfying documentation requirements.

MeSH terms

  • Documentation / methods*
  • Electronic Health Records*
  • Feasibility Studies
  • Humans
  • Medical History Taking
  • Physical Examination