Abstract
BackgroundWe developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers.MethodsTo build our SCDS toolkit, physicians met frequently to develop content, define the cohort, select outcome measures, and delineate factors known to modify disease progression. We assigned tasks to the care team and mapped data elements to the progress note. Programmer analysts built and tested the SCDS toolkit, which included several score tests. Auto scored and interpreted tests included the Generalized Anxiety Disorder 7-item, Center for Epidemiological Studies Depression Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia Severity Index, and the International Restless Legs Syndrome Study Group Rating Scale. The SCDS toolkits also provided clinical decision support (untreated anxiety or depression) and prompted enrollment of patients in a DNA biobank.ResultsThe structured clinical documentation toolkit captures hundreds of fields of discrete data at each office visit. This data can be displayed in tables or graphical form. Best practice advisories within the toolkit alert physicians when a quality improvement opportunity exists. As of May 1, 2019, we have used the toolkit to evaluate 18,105 sleep patients at initial visit. We are also collecting longitudinal data on patients who return for annual visits using the standardized toolkits. We provide a description of our development process and screenshots of our toolkits.ConclusionsThe electronic medical record can be structured to standardize Sleep Medicine office visits, capture data, and support multicenter quality improvement and practice-based research initiatives for sleep patients at the point of care.
Highlights
We developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers
We reviewed the pertinent medical literature, Academy of Neurology (AAN) guidelines (Guidelines, 2019), National Institute of Neurological Diseases and Stroke Common Data Elements (NINDS/NIH, 2015), the American Academy of Sleep Medicine (AASM) (Aurora et al 2012), and the International Restless Legs Syndrome Study Group (IRLSSG) guidelines (Garcia-Borreguero et al 2013)
We employed an SCDS and clinical decision support (CDS) toolkit built within our electronic medical record (EMR) for quality improvement and outcomes research
Summary
We developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers. The American Academy of Neurology (AAN) has proposed quality measures for the care of adults with neurological disease (Cheng 2010; Fountain et al 2011; Miller et al 2013; Odenheimer et al 2013; England et al 2014), and guidelines for restless legs syndrome/ Willis-Ekbom disease (RLS/WED) are under development (Guidelines Projects in Process, 2019). A challenge to EMR documentation is that clinical data are not captured discretely, making it difficult to report performance and assess quality improvement opportunities. Structured clinical documentation support offers a solution to this problem, allowing data to be captured discretely, and making it easier to report performance
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