Standardizing and optimizing institutional-level documentation in the electronic medical record era.

Abstract

155 Background: Although electronic medical records (EMR) offer numerous potential benefits, there are significant challenges to balance high quality patient care and clinical efficiency with the rising demands of required documentation. Our objective was to propose and implement a strategy to standardize and optimize EMR documentation. Methods: An EMR taskforce was created within our institution’s radiation oncology (RO) department consisting of representatives of the clinical staff and EMR coders. To optimize clinical documentation, disease-site specific consult templates were created using EMR standard data elements and personalized drop down menus (Smartlists). Meetings were held with the billing department for template review and with the analytics team to begin automated data extraction into research databases. Quality metrics such as the average number of clinic visits billed at levels 4 or 5 (B45) and the average number of hours per visit (AHV) were compared in different clinics within a 6-month pre- and post- template implementation time period. Results: Within 3 months of establishing the taskforce, 32 RO disease-specific templates were created and distributed for usage in clinic. Optimized template features include consistent cancer staging, standardized oncologic history entry, usage of macros for patients’ symptoms for multiple provider verification, imbedded disease-specific protocol list to improve patient screening and enrollment, and multiple Smartlists for common treatment recommendations. In the GI Clinic, B45 increased from 49.3 to 61.4 per month and similar trends were seen in the Thoracic Clinic (B45, 51.4 to 85.2 per month). The AHV decreased in both the GI (21 to 10 hours) and Thoracic (22 to 13 hours) clinics, showing a significant added value to use of standard documentation. Conclusions: EMR systems can be challenging to navigate; however, they also present a unique opportunity to optimize clinical and research efficiency if used properly. The implementation of standard documentation in our department led to significant improvement in clinical efficiency. Further efforts are being made to adopt these changes on an institutional-wide level.