Electronic Health Record Template Research Articles

Preparing for the Unknown: Simulation-based Training in a New Procedural /PACU Area to Increase Patient Safety

<h3>Background Information</h3> Opening a new procedural area and post anesthesia care unit (PACU) can present potential risk of complications. An education need was identified to establish and test workflows for 3 new procedural areas to ensure patient safety measures. Simulation-based team training was developed for all interdisciplinary team members working in the new setting. <h3>Objectives of Project</h3> The goal of this training was to test new workflows to ensure efficiency and to establish patient safety measures in a new ambulatory procedural and PACU environment. <h3>Process of Implementation</h3> All interdisciplinary team members were surveyed prior to the simulation regarding their experience with simulation training and to assess primary patient safety concerns. Nursing leadership and informatics analysts coordinated the simulation planning. A test patient was developed in the customized electronic health record (EHR) template for the procedural and PACU area. A detailed workflow was developed covering the multiple roles impacting the patient's visit. Test patients were created with three separate scenarios for the different modalities. An additional scenario was included for the activation of the institutional Medical Emergency Rapid Intervention Team (MERIT). A brief was provided prior to each simulation scenario and tasks were assigned based on roles. The scenarios followed the patient from check-in through discharge. Each simulation included several anticipated workflow challenges such as laboratory testing, specimen collection, chest X-rays and MERIT team activation. At the completion of each simulation activity, a debrief session led by PACU nursing leadership was held to discuss identified areas of improvement, patient safety concerns, workflow challenges and team collaboration. Feedback forms were provided during the simulation to record specific patient safety concerns and barriers to providing safe care. A list was compiled to address critical needs prior to the scheduled go-live date. A post-survey was provided to evaluate the effectiveness of the simulation activity. <h3>Statement of Successful Practice</h3> Post-survey results revealed that 91% of participants felt confident and prepared; 76% felt safety concerns were addressed; 18% identified patient safety concerns and all participants felt that their learning needs were met. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Providing simulation training for multidisciplinary teams in a new procedural and PACU area could improve patient outcomes, establish cohesive workflows, and increase knowledge and confidence.

How well do documented goals-of-care discussions for patients with stage IV cancer reflect communication best practices?

BackgroundWritten clinical communication regarding patients’ disease understanding and values may facilitate goal-concordant care, yet little is known about the quality of electronic health record (EHR) documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation.MethodsResearchers pulled text of EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Text was included when in a single encounter the clinician addressed: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Researchers qualitatively coded text based on guidelines for communication best practices, and noted if an EHR template was used.ResultsForty-two percent (206/492) of patients had EHR-documented goals-of-care discussions. Text frequently described communication of cancer progression (89%), though rarely included prognosis (22%). Text often included patients’ goals and values (83%), and at least on specific treatment decision (82%). Communication about treatments was included for 98% of patients; common examples included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians documented making recommendations for 40% of patients. Text addressing patient emotional and spiritual concerns was uncommon (15%). Compared to free text, use of a template was associated with increased documentation of goals and values (80% vs. 61%, p < 0.01), but not other best practices.ConclusionInsights from the study can be used to guide future training and research to study and improve the quality of documentation about goal of care, and its impact on goal-concordant care.

Utilizing a health information exchange to facilitate COVID-19 VA primary care follow-up for Veterans diagnosed in the community.

The use of alerts from the Bronx RHIO, a health information exchange (HIE) to identify James J. Peters VAMC patients diagnosed with COVID-19 in the community was described to facilitate COVID-19 VA primary care follow-up. COVID-19 hospitalization and testing alerts were delivered on a Bronx RHIO facility report. VA COVID-19 follow-up care by telephone and video was guided by local COVID-19 clinical pathways, electronic health record (EHR) templates, and tracking through a database. VA received 180 RHIO alerts for 111 unique patients, and 88 had positive non-VA testing from March to June 2020. 41% of the 88 had non-VA admissions and 23% died. 63% received VA primary care follow-up of COVID-19 symptoms documented by custom EHR templates. The HIE identified 11% of the facility COVID-19 patients. HIE alerts can be used to identify facility COVID-19 patients diagnosed in the community and facilitate follow-up by their VA primary care teams.

A Focus on Congestive Heart Failure-Related Patient Education After Open Heart Surgery: A Quality Improvement Project.

After open heart surgery patients often develop symptoms associated with congestive heart failure (CHF), or fluid volume overload. To prevent heart failure-related symptoms in the postoperative period patients must be educated on heart failure self-care. To decrease the percentage of postoperative open heart surgical patients with CHF-related questions and concerns from 44% to 30% by March 2020. A cardiac surgery educational booklet and an educational electronic health record template were identified to guide a CHF educational pathway. Intensive care staff nurses provided patient education after surgery. PDSA cycles were performed in succession to roll out the quality improvement (QI) initiative. Of patients experiencing postoperative issues, 44% of patients developed symptoms or concerns related to heart failure. Upon implementation of the CHF-focused pathway 15% of patients were exhibiting symptoms or concerns related to CHF, out of all patients with postoperative issues. CHF, and fluid volume overload continues to be a difficult pathology requiring close management and follow up. After open heart surgery, providing concise, CHF-focused education results in reduced CHF-related patient concerns after discharge. By providing a disease-focused patient education nurses can reduce the complications that patients develop after an inpatient hospital.

Improving Pediatric Residents' Screening for Access to Firearms in High-Risk Patients Presenting to the Emergency Department.

Access to a firearm is a significant risk for completed suicide or homicide. We sought to increase the rate of screening for access to firearms in patients who presented to the emergency department with suicidal or homicidal ideation or suicide attempt through the use of quality improvement methodology. Patient records were eligible for inclusion if the child was under the age of 19 and presented to the emergency room of our tertiary medical center with a diagnosis of suicidal ideation, homicidal ideation, or suicide attempt. Records were manually reviewed for demographic information and documentation of screening for access to firearms. A baseline survey of the pediatric residents was completed to identify perceived barriers to screening for access to firearms. Subsequently, three "Plan, Do, Study, Act" (PDSA) cycles consisting of a noon conference, a dedicated grand rounds, and an electronic health record template were completed. During the baseline and study period, 501 patients met inclusion criteria. Forty-one of sixty-six (62.1%) residents completed a baseline survey and identified barriers to screening. There was no significant increase in screening following the first or second PDSA cycles. Following the third PDSA cycle, screening rates increased from 4% to 34%. Quality improvement methodology can be used to increase the rates of screening for access to firearms in high-risk patients. Further work is necessary to identify additional strategies to further increase screening rates.

Postpartum Note Template Implementation Demonstrates Adherence to Recommended Counseling Guidelines.

Postpartum visits may provide patients with an inadequate amount of counseling on postpartum depression, birth spacing, healthy eating, exercise, or changes in sexual response and emotions. We created a template in our electronic health record (EHR) with the aid of our clinical informatics department to increased adherence with recommended counseling guidelines. We retrospectively reviewed the postpartum visits of 200 patients who had a delivery and received postpartum care. Patients were seen in a resident-run clinic: 100 visits occurred prior to implementation of the template, while 100 visits occurred post-implementation with use of the template. We observed for documentation of counseling on Pap smear, birth spacing, breastfeeding, contraception, depression, gestational diabetes mellitus, pre-eclampsia, and sleep/fatigue. Descriptive statistics of mean and standard deviation were used to describe the continuous variables. Frequency and percentage were used to describe the continuous variables. Analysis of variance compared the continuous variables. The Pearson chi-square test compared the categorical variables. In visits that occurred without use of the template, counseling was charted as low as 1.0% for birth spacing to as high as 86.0% for contraception. With use of the template, counseling was charted as 100% in all visits for each of the recommended counseling guidelines (all p < 0.001). In conclusion, an EHR template for documentation of postpartum visits is associated with resident adherence with recommended postpartum counseling guidelines. Managers in hospitals and clinical practices should consider incorporating OBGYN-specific EHR note templates to improve quality and increase adherence with recommended guidelines during postpartum visits.

Taking prevention to the next step: implementation of a brief, sustainable frailty assessment in a cardiology clinic

BackgroundFrailty measurement is recommended when assessing older adults with cardiovascular disease to individualise prevention and treatment. We sought to address this by incorporating routine gait speed measurement by clinicians into...

Embedding Patient Priorities Care in an Age-Friendly Health System

Background: Patient Priorities Care (PPC) is an innovative approach to improving care for older adults with multiple morbidities. We developed a PPC training program for healthcare professionals and describe preliminary results. Methods: We implemented PPC in a geriatrics clinic. 20 staff and trainees participated on 1) how to identify patient priorities, 2) documentation in the electronic health record (EHR), and 3) strategies to align care with priorities; and received case-based audit and feedback. Results: 250 patients participated in PPC encounters. The EHR template was subsequently integrated within an Age Friendly Health System (AFHS) note. Clinicians have integrated this AFHS template for all encounters. Conclusion: PPC is a feasible approach to the care of older adults with multiple morbidities following a structured clinician training program. PPC can be effectively incorporated into the “Matter Most” component of AFHS.

Template Design and Analysis: Integrating Informatics Solutions to Improve Clinical Documentation.

Electronic health record templates have served a variety of functions, such as improving documentation for reliable reporting of health care outcomes. Standardizing template documentation has been important for accurately capturing case workload and supporting quality improvement initiatives. North Florida/South Georgia Veterans Health System consists of 2 Florida-based hospitals: Malcom Randall Veterans Affairs Medical Center (MRVAMC) in Gainesville, and Lake City Veterans Affairs Medical Center (LCVAMC). In the first quarter of fiscal year 2017, MRVAMC and LCVAMC had a below-average case severity index (CSI) of 0.76 and 0.81, respectively, compared with that of the 0.96 national average for the Veterans Health Administration (VHA). An innovative history and physical template design with embedded informatics tools was created to improve clinical documentation. Compliance with standardized history and physical medicine template use was monitored for about 1 year after standardized template implementation. Compliance improved from 43.2% in June 2018 to 89.9% in June 2019 at MRVAMC and increased from 48.2% in June 2018 to 96.9% in June 2019 at LCVAMC. CSI improved to 0.97 at MRVAMC and 1.07 at LCVAMC in the first quarter of fiscal year 2019, which exceeded the VHA national average of 0.89 during the same period. NF/SGVHS integrated informatics solutions within template design was associated with an increase in CSI via improved clinical documentation.

Annals for Educators - 1 September 2020.

Annals for Educators - 1 September 2020.

Leveraging an electronic health record note template to standardize screening and testing for COVID-19

The coronavirus disease 2019 (COVID-19) pandemic challenged health care organizations to develop ways to provide patient care with rapidly changing guidelines and scarce resources. Clinical leaders and informatics specialists partnered to rapidly develop an electronic health record (EHR) template for primary care staff to screen Veterans at Veterans Affairs (VA) Puget Sound. The template prompts categorization of patients by stability and suspicion for COVID-19, and provides just-in-time triaging advice for clinic staff. Each category is a discrete data element and this information was used by leadership to track screening and testing volumes. We found that a brief, practical EHR note template can be quickly adopted to inform guideline-based screening, direct patient care, and conserve resources.

Improving the Frequency and Documentation of Gun Safety Counseling in a Resident Primary Care Clinic.

Increase the frequency and documentation of gun safety discussions during well-child checks in the pediatric primary care resident clinic to 50% within 6 months. This is a quality improvement study in a pediatric resident continuity clinic. Before implementing any interventions, a survey was conducted to understand residents' attitudes and practices regarding gun safety screening and counseling. Interventions included a parent safety survey, Be SMART materials in clinic, and a prompt embedded into Electronic Health Record templates. Chart reviews were conducted to determine frequency of gun safety discussion. Resident self-reported comfort with gun safety counseling was also evaluated. A statistical process control chart was generated to track documentation and found the baseline mean rate of gun safety discussions during well-child checks was 3%. Rates increased following the addition of the Electronic Health Record prompt, with the mean further increased to 84% in July 2019. A sustained rate of over 75% was achieved through February 2020. Over 4 study months, the proportion of trainees reporting feeling very uncomfortable/uncomfortable with gun safety counseling decreased from 22% to 15%. The Be SMART program was identified as a key intervention increasing gun safety counseling. Our study identified an effective approach to improving the frequency and documentation of gun safety discussions in an academic primary care setting, providing a unique blueprint for firearm screening and safe storage counseling success. Ultimately, we believe this will increase safe storage behaviors in the home and reduce risks of child death from firearms.

Implementation and sustainability of a medication reconciliation toolkit: A mixed methods evaluation

MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) provided participating hospitals with a toolkit to assist in developing robust medication reconciliation programs. Here we describe hospitals' implementation of the MARQUIS toolkit, barriers and facilitators, and important factors that may enhance the spread and sustainability of the toolkit. We used a mixed methods, quantitative-qualitative study design. We invited site leaders of the 5 hospitals that participated in MARQUIS to complete a Web-based survey and phone interview. The Consolidated Framework for Implementation Research guided question development. We analyzed the collected data using descriptive statistics (for survey responses) and thematic content analysis (for interview results). Site leaders from each MARQUIS hospital participated. They reported that MARQUIS toolkit implementation augmented their hospitals' existing but limited medication reconciliation practices. Survey results indicated executive leadership support for toolkit implementation but limited institutional support for hiring staff (reported by 20% of respondents) and/or budgetary support for implementation (reported by 60% of respondents). Most participating hospitals (80%) shifted staff responsibilities to support medication reconciliation. Interview findings showed that inner setting (ie, organizational setting) and process factors (eg, designation of champions) both inhibited and facilitated implementation. Hospitals adopted a variety of toolkit interventions (eg, discharge medication counseling) using a range of implementation strategies, including development of educational tools and tip sheets for staff members and electronic health record templates. Despite limited institutional support, hospitals can successfully implement, spread, and sustain the MARQUIS toolkit by shifting staff responsibilities, adding pharmacy staff, and using a variety of strategies to facilitate implementation. Although leadership support and resources for data collection and dissemination facilitated implementation, limited staff buy-in and competing priorities may hinder implementation.

Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer.

Background: Serious illness conversations are part of advance care planning (ACP) and focus on prognosis, values, and goals in patients who are seriously ill. To be maximally effective, such conversations must be documented accurately and be easily accessible. Objectives: The two coprimary objectives of the study were to assess concordance between written documentation and recorded audiotaped conversations, and to evaluate adherence to the Serious Illness Conversation Guide questions. Methods: Data were obtained as part of a trial in patients with advanced cancer. Clinicians were trained to use a guide to conduct and document serious illness conversations. Conversations were audiotaped. Two researchers independently compared audiorecordings with the corresponding documentation in an electronic health record (EHR) template and free-text progress notes, and rated the degree of concordance and adherence. Results: We reviewed a total of 25 audiorecordings. Clinicians addressed 87% of the conversation guide elements. Prognosis was discussed least frequently, only in 55% of the patients who wanted that information. Documentation was fully concordant with the conversation 43% of the time. Concordance was best when documenting family matters and goals, and least frequently concordant when documenting prognostic communication. Most conversations (64%) were documented in the template, a minority (28%) only in progress notes and two conversations (8%) were not documented. Concordance was better when the template was used (62% vs. 28%). Conclusion: Clinicians adhered well to the conversation guide. However, key information elicited was documented and fully concordant less than half the time. Greater concordance was observed when clinicians used a prespecified template. The combined use of a guide and EHR template holds promise for ACP conversations.

Information Technology-Based Management of Clinically Healthy COVID-19 Patients: Lessons From a Living and Treatment Support Center Operated by Seoul National University Hospital.

BackgroundSouth Korea took preemptive action against coronavirus disease (COVID-19) by implementing extensive testing, thorough epidemiological investigation, strict social distancing, and rapid treatment of patients according to disease severity. The Korean government entrusted large-scale hospitals with the operation of living and treatment support centers (LTSCs) for the management for clinically healthy COVID-19 patients.ObjectiveThe aim of this paper is to introduce our experience implementing information and communications technology (ICT)-based remote patient management systems at a COVID-19 LTSC.MethodsWe adopted new electronic health record templates, hospital information system (HIS) dashboards, cloud-based medical image sharing, a mobile app, and smart vital sign monitoring devices.ResultsEnhancements were made to the HIS to assist in the workflow and care of patients in the LTSC. A dashboard was created for the medical staff to view the vital signs and symptoms of all patients. Patients used a mobile app to consult with their physician or nurse, answer questionnaires, and input self-measured vital signs; the results were uploaded to the hospital information system in real time. Cloud-based image sharing enabled interoperability between medical institutions. Korea’s strategy of aggressive mitigation has “flattened the curve” of the rate of infection. A multidisciplinary approach was integral to develop systems supporting patient care and management at the living and treatment support center as quickly as possible.ConclusionsFaced with a novel infectious disease, we describe the implementation and experience of applying an ICT-based patient management system in the LTSC affiliated with Seoul National University Hospital. ICT-based tools and applications are increasingly important in health care, and we hope that our experience will provide insight into future technology-based infectious disease responses.

Prospective, Blinded Evaluation of Template-Based Cesarean Documentation Error in an Obstetric Training Program.

Cesarean operative report accuracy impacts postoperative care and future obstetric decision-making. The impact of electronic health record template use on cesarean documentation error remains unknown. The aim of the study was to describe the incidence of resident physician documentation error in cesarean operative reports using electronic health record templates. Attending physicians completed a standardized audit form after cesarean deliveries, which was compared with the resident operative report. Resident physicians were blinded to the auditing process. Errors were classified as none, major, or minor using predefined definitions. Author and operative characteristics were collected for comparative and predictive analyses. Data were analyzed by presence or absence of error. We reviewed 100 cesarean operative reports. Major and minor errors were encountered in 33% and 53% of operative notes, respectively. Advancing training level was associated with lower incidence of major error (50%, for postgraduate year [PGY] 1, 33% for PGY 2, and 0% for PGY 3/4, P = 0.02), but minor errors were similar among training level, P = 0.48. Operative duration, documentation interval, and shift characteristics were similar in cases with and without documentation errors. In multiple logistic regression, PGY was predictive of major documentation error (adjusted odds ratio = 0.39, 95% confidence interval = 0.17-0.92). A high incidence of clinically significant documentation error was observed in a residency training program using standardized templates for cesarean operative reports. Incidence of major error decreased with increasing training, but minor error was similar across levels of training. These data suggest that measures should be taken to improve documentation accuracy in medical training to provide optimal obstetric care.

Deprescribing Proton Pump Inhibitors in an Academic, Primary Care Clinic: Quality Improvement Project.

The goal of this study was to reduce the percentage of inappropriately prescribed proton pump inhibitors (PPIs) in patients aged 50 and older from 80% (baseline) to 60% within 12 months in an academic, internal medicine clinic. The use of PPIs has increased drastically worldwide. Internal medicine clinic patients had inappropriate use of PPIs for an average of 4 to 5 years. A multidisciplinary quality improvement team used the Plan-Do-Study-Act Model of health care improvement and performed a root cause analysis to identify barriers to inappropriate use of PPIs. The outcome measure was the percentage of patients inappropriately prescribed PPI. Process measures were completion rates of PPI risk assessment and esophagogastroduodenoscopy. Interventions included the creation of customized electronic health record templates and education to providers and patients. Analysis was performed using monthly statistical process control charts. The average rate of PPI discontinuation was 51.1% (n=92/180), which corresponds to 30.0% inappropriate PPI usage within 12 months. The mean PPI discontinuation rate in the 1-year prestudy, study and 6 months poststudy period was 2.0%, 32.0%, and 49.7%, respectively. The mean esophagogastroduodenoscopy completion rate was 49.8% from the baseline of <30%. We achieved a statistically significant and sustainable reduction of inappropriate PPI use to 30% from the baseline rates of 80% and surpassed our goal within 12 months. This quality improvement was unique as no pharmacy personnel was utilized in this process. The multifaceted strategies in a safety-net internal medicine clinic resulted in successful deprescribing of PPI and can be replicated in other setting.

Improving Asthma in Pediatric Practice

Pediatric asthma is a significant public health problem. It is the third cause of pediatric hospitalizations, costing $20 billion in 2016. In the US, approximately 6 million children have asthma. Despite available guidelines, implementation is lagging with only 35 % of providers using guidelines. The question was does provider compliance of the NAEPP 2007 asthma guidelines improve through an electronic health record (EHR) template in a pediatric primary care practice?" A quality improvement project implemented an EHR template for pediatric asthma visits and provider education to support the compliance of following the NAEEP 2007 asthma guidelines. A retrospective EHR chart review of charts within the same seasonal time frame, ages 5-12yrs was done to determine documentation pre-and post-project implementation. The chi- square was used for statistical significance. Data reviewed were documentation of action plan, severity, adherence to follow-up appointment, prescribing of prevention medication, ED visits and hospitalizations, C-ACT score, spirometry use, education, and missed school days. Documentation of asthma action plan increased from 10 % to 74 % p = 0.001., spirometry rose from 4% to 32 % p =.011, asthma education increased from 60 % to 98% p=.000, follow up adherence rose from 60% to 98% p = .000 and asthma severity categorized improved from 32% to 100 % p=. 011. Statistical significance was shown in 7 out of the 8 quality measurements. The area of prescribing controller medication for persistent asthma showed clinical significance with 58% to 100% improvement, but was not statistically significant (p=.258) because clinical knowledge was present with the providers prior to the intervention on managing persistent asthma. Results support the hypothesis that an EHR template with evidence-based guidelines improved provider documentation of an asthma action plan, severity, follow-up, and prescribing control medication, ED visits, hospitalizations, missed school days, C-ACT score, spirometry and asthma education. View a PDF of this Poster Presentation

Translating Discharge Instructions for Limited English-Proficient Families: Strategies and Barriers.

Access to written hospital discharge instructions improves caregiver understanding and patient outcomes. However, nearly half of hospitals do not translate discharge instructions, and little is known about why. To identify barriers to and potential strategies for translating children's hospital discharge instructions. We conducted a mixed-methods, multimodal analysis. Data comprised closed- and open-ended responses to an online survey sent to Children's Hospital Association language services contacts (n = 31), an online environmental scan of Children's Hospital Association translation policies (n = 22), and county-level census data. We examined quantitative data using descriptive statistics and analyzed open-ended survey responses and written policies using inductive qualitative content analysis. Most survey respondents (81%) reported having a written translation policy at their hospital, and all reported translating a subset of hospital documents, for example, consent forms. Most but not all reported translating discharge instructions (74%). When asked how inpatient staff typically provide translated discharge instructions, most reported use of pretranslated documents (87%) or staff interpreters (81%). Reported barriers included difficulty translating uncommon languages, mismatched discharge and translation time frames, and inconsistent clinical staff use of translation services. Strategies to address barriers included document libraries, pretranslated electronic health record templates, staff-edited machine translations, and sight translation. Institutional policies differed regarding the appropriateness of allowing interpreters to assist with translation. Respondents agreed that machine translation should not be used alone. Children's hospitals experience similar operational and organizational barriers in providing language-concordant discharge instructions. Current strategies focus on translating standardized documents; collaboration and innovation may encourage provision of personalized documents.

Addressing alcohol misuse in primary care.

Alcohol misuse (AM) among young adults remains a public health issue that is underaddressed in primary care. Despite well-supported recommendations to screen and offer brief interventions for AM, most primary care providers do not address the issue. Increasing rates of alcohol-related incidents and lack of a standardized alcohol Screening and Brief Intervention (SBI) program were identified in a private university health center. Nurse practitioners, staff nurses, and physicians received education on alcohol SBI. Young adult students visiting a college health center were administered the Alcohol Use Disorders Identification Test-Consumption electronically followed by a brief motivational intervention if they screened positive using embedded Electronic Health Record templates. Preimplementation/postimplementation chart audit and surveys were used to evaluate effectiveness. Following staff education, a standardized alcohol SBI program was implemented in a private university health center. Increased alcohol screening and intervention rates, as well as increased knowledge about AM, and reduced alcohol use among participants were identified. Through staff education and by embedding standard alcohol SBI templates, more at-risk young adults were identified and rendered alcohol interventions during routine visits. This replicable program can improve outcomes related to AM in the primary care setting.