Abstract
AbstractCystic fibrosis (CF) is a genetic disease in which dysfunction of a single protein channel leads to organ damage, resulting in chronic health problems and premature death. In the United States, medical care of individuals living with CF is delivered by care centers accredited and subsidized by the CF Foundation. CF outcomes have improved significantly through the use of collaborative networks, registry data, and research. CF clinicians are perpetually challenged to assimilate and act upon large quantities of data generated by the care of these individuals. CF Foundation accreditation also requires care centers to enter patient-level data from clinical encounters into the CF Foundation Patient Registry (CFFPR). Commercially available electronic health record systems often lack tools with sufficient context specificity and ease of use to facilitate productive interactions between clinicians and patients. We describe a CF-specific NoteWriter template built and implemented in Epic, which captures discrete data and simultaneously generates clinical documentation during ambulatory encounters. Unlike other examples of note templates in CF, this project involves SmartData Elements (SDEs) using the NoteWriter tool in Epic, which enables data to be entered in the exact way in which the CFFPR captures data. By conducting a pre-/poststudy of its use in our health system, we found that the template can expedite note completion when clinicians have adequate time to become familiar with the tool. We anticipate that the NoteWriter template will become a vehicle for delivering standardized, structured patient data to the CFFPR.
Highlights
Background and SignificanceModern electronic health records (EHRs) are sophisticated platforms that assimilate a vast array of patient data and present information to clinicians through a graphical user interface
Effects of the Cystic fibrosis (CF) NoteWriter Template on the Efficiency of Clinician Documentation Data were extracted for review from five clinicians, providing outpatient CF care before and after the CF NoteWriter template became available (►Table 1)
Two clinicians had no significant difference in time to completion between the two documentation strategies
Summary
Background and SignificanceModern electronic health records (EHRs) are sophisticated platforms that assimilate a vast array of patient data and present information to clinicians through a graphical user interface. After passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, which authorized up to $27 billion in Medicare and federal Medicaid payments over 10 years to qualified health care entities,[1] EHR adoption surged.[2,3] To capitalize on this incentive, health care entities must demonstrate meaningful use.[4] clinicians experience significantly increased screen time to assiduously document their efforts in the EHR. Recent studies have revealed that clinicians spend at least as much time charting in the EHR environment as they do conversing with their patients.[5,6,7] Being unable to disengage from the EHR, after hours, may contribute to physician burnout.[8,9] improved documentation strategies are needed to mitigate the tension between fulfilling meaningful use mandates and preserving clinician job satisfaction
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