We present activeNotes, an application that supports the creation of Critical Care Notes by physicians in a hospital intensive care unit. ActiveNotes integrates automated, context-sensitive patient data retrieval and user control of automated data updates and alerts into the note-creation process. In a user study at New York Presbyterian Hospital, we gathered qualitative feedback on the prototype from 15 physicians. The physicians found activeNotes to be valuable and said they would use it to create both formal notes for medical records and informal notes. One surprising finding is that while physicians have rejected template-based clinical documentation systems in the past, they expressed a desire to use activeNotes to create personalized, physician-specific note templates to be reused with a given patient, or for a given condition.
By: Lauren Wilcox; Jie Lu; Jennifer Lai; Steven Feiner; Desmond Jordan
Published in: RC24747 in 2009
LIMITED DISTRIBUTION NOTICE:
This Research Report is available. This report has been submitted for publication outside of IBM and will probably be copyrighted if accepted for publication. It has been issued as a Research Report for early dissemination of its contents. In view of the transfer of copyright to the outside publisher, its distribution outside of IBM prior to publication should be limited to peer communications and specific requests. After outside publication, requests should be filled only by reprints or legally obtained copies of the article (e.g., payment of royalties). I have read and understand this notice and am a member of the scientific community outside or inside of IBM seeking a single copy only.
Questions about this service can be mailed to reports@us.ibm.com .