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First published April 2, 2004 as JAMIA PrePrint; doi:10.1197/jamia.M1461
Journal of the American Medical Informatics Association 2004;11(4):310-315
© 2004 American Medical Informatics Association


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Submitted on September 19, 2003
Accepted on March 16, 2004

Experience in Implementing Inpatient Clinical Note Capture via a Provider Order Entry System

S. Trent Rosenbloom MD, MPH1*, Jonathan Grande BS1, Antoine Geissbuhler MD2, and Randolph A. Miller MD1

Affiliation of the authors: 1 Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN; 2 Medical Informatics, Geneva University Hospitals, Geneva, Switzerland

* To whom correspondence should be addressed.

Care providers' adoption of computer-based health-related documentation (note capture) tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note capture tool that has been made available to end-users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note capture tool usage between January 1, 1999 and December 31, 2001 increased substantially, both in the number of users and their frequency of use. This Case Report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer assisted documentation tool - a concept that may seem counterintuitive to some.




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