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

Affiliations of the authors: Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN (STR, JG, RAM); Division of Medical Informatics, Geneva University Hospital, Geneva, Switzerland (AG).

Correspondence and reprints: S. Trent Rosenbloom, MD, MPH, Eskind Biomedical Library, Room 442, 2209 Garland Avenue, Nashville, TN 37232-8340; e-mail: <trent.rosenbloom{at}vanderbilt.edu>

Received for publication: 09/19/03; accepted for publication: 03/16/04.

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 in 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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