Electronic Medical Record Documentation Research Articles

Acute Care Physical Therapy and Occupational Therapy Involvement throughout Implementation of a Hospital Electronic Health Record

Purpose: To describe processes, opportunities and challenges encountered by an acute care rehabilitation department during electronic medical record (EMR) implementation. The EMR can enhance quality, safety and efficiency but hospital adoption has been slow. Due to widespread support and financial incentives, implementation of certain areas of the EMR, such as medication administration and order entry, has become more prevalent. Methods: During the design phase of EMR implementation, rehabilitation managers participated in several committees including system development and hospital infrastructure hardware assessment. For rehabilitation staff, EMR education was multimodal utilizing a train-the-trainer approach, including computer-based training, face-to-face, and classroom education. Due to resource constraints, the Information Technology department provided limited support to build and implement rehabilitation EMR documentation. The rehabilitation department took the initiative to internally develop and implement electronic documentation utilizing tools offered within EMR software. Results: Average visits temporarily declined by 13.7% for PT and 8.4% for OT during EMR implementation; the volume of treatments returned to previous numbers after implementation. EMR implementation decreased the need for aide staff to spend time and resources to support the paper medical record. Conclusion: EMR committees offered a direct line to provide input and troubleshoot EMR issues and increased awareness of options and processes. This empowered the rehabilitation department to seek creative ways to develop electronic documentation.

Improving Efficiency in Active Surveillance for Methicillin-Resistant Staphylococcus aureus or Vancomycin-Resistant Enterococcus at Hospital Admission

Mandatory active surveillance culturing of all patients admitted to Veterans Affairs (VA) hospitals carries substantial economic costs. Clinical prediction rules have been used elsewhere to identify patients at high risk of colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). We aimed to derive and evaluate the clinical efficacy of prediction rules for MRSA and VRE colonization in a VA hospital. Design and setting. Prospective cohort of adult inpatients admitted to the medical and surgical wards of a 119-bed tertiary care VA hospital. Within 48 hours after admission, patients gave consent, completed a 44-item risk factor questionnaire, and provided nasal culture samples for MRSA testing. A subset provided perirectal culture samples for VRE testing. Of 598 patients enrolled from August 30, 2007, through October 30, 2009, 585 provided nares samples and 239 provided perirectal samples. The prevalence of MRSA was 10.4% (61 of 585) (15.0% in patients with and 5.6% in patients without electronic medical record (EMR)-documented antibiotic use during the past year; P < .01). The prevalence of VRE was 6.3% (15 of 239) (11.3% in patients with and 0.9% in patients without EMR-documented antibiotic use; P < .01). The use of EMR-documented antibiotic use during the past year as the predictive rule for screening identified 242.8 (84%) of 290.6 subsequent days of exposure to MRSA and 60.0 (98%) of 61.0 subsequent days of exposure to VRE, respectively. EMR documentation of antibiotic use during the past year identified 301 (51%) of 585 patients as high-risk patients for whom additional testing with active surveillance culturing would be appropriate. EMR documentation of antibiotic use during the year prior to admission identifies most MRSA and nearly all VRE transmission risk with surveillance culture sampling of only 51% of patients. This approach has substantial cost savings compared with the practice of universal active surveillance.

Comparison of documentation time between an electronic and a paper-based record system by optometrists at an eye hospital in south India: A time–motion study

Purpose The adoption of electronic medical record (EMR) system is gradually increasing. However, various time–motion studies reveal conflicting data regarding time effectiveness on workflow due to computerization. One of the major issues for physicians is their uncertainty with EMRs’ potential impact of time on workflow. A tertiary eye hospital in south India was in the process of implementing an EMR system in their ambulatory care unit. Many of the staff did not have previous computing experience and there were conflicting views on the time effectiveness of the computerized system after implementation. The management was thus interested to know the real time effectiveness of EMR in their hospital. The study compliments existing studies of this type by comparing the time efficiency of documentation time using EMR system with paper documentation in a hospital in a developing country where a transition between paper and EMR documentation was currently in progress. Methods Ten randomly selected optometrists documented the time they spent during consultation with both paper and EMR documentation. The time spent was documented for a total of 200 records (100 EMR and 100 paper records). The independent-samples t-test and analysis of variance were used to compare the means of the consultation time and calculated documentation time spent between the electronic and paper records. Results There was no statistically significant difference in the time spent for documentation between electronic and paper records. The mean time spent in documenting electronic records was 0.92 min (95% CI −3.06 to 1.14) longer than in paper records. Conclusion EMR systems can be adopted in eye hospitals without having significant negative impact on duration of consultation and documentation for optometrists. More time–motion studies that include ophthalmologists are however needed in order to get a more complete picture of time impact of the EMR system on clinical workflow in eye hospitals.

Implementation of Standardized Nomenclature in the Electronic Medical Record

To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation. Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity. Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation.

Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.

Concern is growing about missed test results, but data assessing their effect on patient safety are limited. To examine the frequency with which computed tomography (CT)-documented dilations of the abdominal aorta are accompanied by evidence in the electronic medical record (EMR) that a clinician recognized the abnormality. Retrospective cohort study. 2 hospitals in the Veterans Affairs Health Care System. Patients with new dilations of the abdominal aorta detected on CT performed in 2003. Radiology report and EMR evidence that the radiologist notified the clinical service, aneurysm size, and interval between CT and EMR recognition. Computed tomography scans of 4112 patients were reviewed and 440 (11%) aortic dilations were identified, of which 91 were new findings. Radiologists directly notified clinical teams about 5 (5%) new dilations. Clinical teams did not record in the EMR recognition of 53 of 91 (58%) dilations within 3 months of the CT, and 9% of these dilations were 5.5 cm or larger. The median time to recognition of aneurysm in the EMR was 237 days, and no EMR documentation existed for 16 abnormalities (29% of surviving patients) during a mean follow-up of 3.2 years. No evidence indicated that any of the aneurysms ruptured or that patient deaths resulted from the delayed follow-up. Clinicians may have recognized some aneurysms but did not document them in the EMR. Clinicians neglect to note a substantial proportion of new aortic dilations in the EMR. The findings highlight the need for better strategies to ensure documentation of follow-up of tests.

Improving the quality of pediatric pain: utilizing the EMR for the assessment and management of pediatric pain

Optimal pain management requires compliance with objective assessments, interventions, monitoring and documentation. Optimal documentation has been challenging for many organizations. At Children's National Medical Center the electronic medical record (EMR) was introduced to include provider documentation of pain assessment before and after intervention. We hypothesized that assessment of pain would improve by combining EMR documentation with quality improvement methods. A multidisciplinary team designed a monthly automated pain assessment report using EMR-derived data.

The impact of ethnicity and gender on agreement of severe allergy history between inpatient and outpatient electronic medical records.

To evaluate the rate of allergy documentation during inpatient admissions and determine if discrepancies exist between ethnicities and English proficiency, genders, and by medication classes. Patients at an outpatient clinic with severe medication allergies documented in their electronic medical record were identified. Inpatient hospital admissions following the date this allergy was documented were reviewed and the presence or absence of this documentation in the inpatient electronic medical record was noted. An overall rate of successful documentation of allergies was calculated by dividing the number of admissions where the allergy was entered into by the total number of admissions where the opportunity to enter the allergy existed. Each patients ethnicity, gender, and the class of medication to which they were allergic to, was also recorded to determine if difference exist within each demographic. Overall, allergy information was successfully entered in 84.6% of 246 hospital admissions. This rate was significantly lower (37.5%) among patients whose ethnicity groups, on average, have lower rates of English fluency. There was no significant difference between genders. Allergies to cephalosporins were less likely to be entered (44.4%). Patients who are not proficient in speaking English may be at an increased risk of experiencing an adverse drug reaction as their severe allergies are less likely to be documented during a hospital admission.

Variations in Compliance With Documentation Using Computerized Obstetric Records

To explore factors that affect documentation completeness using an electronic medical record with a decision support system for obstetrics. Two thousand eight hundred nine consecutive deliveries were analyzed and data were obtained from structured fields in the decision support system. The decision support system was customized to deactivate the system's repetitive prompts and reminders for documentation completeness for the chosen study parameters. Completion of documentation for estimated fetal weight, pelvic adequacy, and fetal position were selected as outcome variables. One point was given for each missing item. Data were analyzed using general linear univariable models. Tukey's honest difference method was used to adjust the P values for potential multiple comparison biases. Midwives had fewer missing items (score 1.42) than both attendings (1.87) and residents (1.74), P<.01. When comparing the following groups, the mean scores differed significantly: vaginal birth after cesarean and repeat cesarean delivery, 1.95 and 1.83 (P<.04); neonatal intensive care unit admission and regular nursery, 1.96 and 1.82 (P<.05). Patients experiencing normal and abnormal labors were similar in documentation completeness, but patients who lacked enough data to have their labors classified were significantly less likely to have complete documentation for the chosen outcome variables. Compliance with documentation in electronic medical record is very low when the reminders for documentation completeness are deactivated and varies with type of provider, as well as with some clinical aspects of the patient.

Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record

Objective The aim of the study was to describe a paper-based, template-driven and an electronic medical record used for capturing emergency care clinical information and to compare the accuracy of these documentation systems for coding patient encounters using the American Medical Association Current Procedural Terminology-2004 (AMA CPT-2004) evaluation and management codes intended for provider reimbursement. Methods A retrospective, cross-sectional study of 4-consecutive-day samples of ED patient encounter records from 2 similar community hospitals was done. For clinical documentation, hospital A uses an electronic medical record, whereas hospital B uses a paper-based template-driven record. Using a simple analytic model, expert coders A and B, respectively, coded the records from hospitals A and B for completeness. First, power analysis determined the acceptability of the patient record sample sizes (1 − β = .90 at 1% significance level), and the frequency of AMA CPT-2004 primary evaluation and management codes 99281 through 99285 was calculated. Second, the completeness discrepancy rates for hospitals A and B were compared to determine the accuracy of both the paper-based, template-driven record and the electronic medical record in documenting and representing the clinical encounter. Third, interrater reliability between expert coders A and B was calculated to assess the level of agreement between each expert coder in determining the completeness discrepancy rates between hospitals A and B. Finally, the frequency of primary evaluation and management codes was analyzed to determine if there was a statistically significant difference between the paper-based, template-driven record and the electronic medical record representation of the clinical information, and if that difference could be attributable to the differing clinical documentation systems used in hospitals A and B. Results First, descriptive display demonstrated a difference in the frequency of the primary evaluation and management codes 99283 and 99284 within hospital A (expert coder A assessment, 36.1% vs 39.1%; expert coder B assessment, 36.6% vs 38.7%) and hospital B (expert coder A assessment, 47.8% vs 21.9%; expert coder B assessment, 48.6% vs 21.4%) was noted with the median, primary evaluation, and management code for hospital A of 99284 and the median, primary evaluation, and management code for hospital B of 99283. Second, Fisher exact test compared the completeness discrepancy rates between hospitals A and B as assessed by each expert coder and demonstrated no statistically significant difference in the completeness discrepancy rates (accuracy) between the paper-based, template-driven record and the electronic medical record documentation and coding system when assessed by either expert coder A ( P = .370) or expert coder B ( P = .819). Third, interrater reliability between expert coders A and B was evaluated using Cohen's κ statistic. When evaluated both individually and jointly with respect to hospitals A and B, expert coders A and B had a good strength of agreement in their assessments of the accuracy of the documentation and coding system for hospital A ( κ = 0.6200) and hospital B ( κ = 0.6906) as well as for both hospitals evaluated together ( κ = 0.6616). Finally, interhospital differences in the frequency of primary evaluation and management codes were evaluated using Pearson χ 2 test with 3 df. The results for expert coder A ( χ 2 = 47.4160; P < .001) and expert coder B ( χ 2 = 46.5946; P < .001) recognize that there is a statistically significant degree of difference between hospitals A and B in the frequency distribution of primary evaluation and management codes, probably because of the dispersion of codes 99283 and 99284. Conclusions A keystroke-driven, electronic medical record that resides on a knowledge platform that incorporates a clinical structured terminology, administrative coding schemata, AMA CPT-2004 codes and uses object-oriented, open-ended, branching chain clinical algorithms that “force” physician documentation of the clinical elements provides an equally accurate capture and representation of ED clinical encounter data as a paper-based, template-driven documentation system both in terms of the presence or absence of both the medically necessary, discrete data elements and the textual documentation-dependent, medical decision-making elements.

Measuring provider adherence to tobacco treatment guidelines: A comparison of electronic medical record review, patient survey, and provider survey

An accurate method of measuring primary care providers' tobacco counseling actions is needed for monitoring adherence to clinical practice guidelines. We compared three methods of measuring providers' tobacco counseling practices: electronic medical record (EMR) review, patient survey, and provider survey. We mailed a survey to 1,613 smokers seen by 114 Boston-area primary care providers during a 2-month period to assess what tobacco counseling actions had occurred at the visit (N = 766; 47% response rate). Smokers' reports were compared with the EMR and with their providers' self-reported usual tobacco counseling practices, derived from a provider survey (N = 110; 96% response rate). Patients reported receiving each counseling action more frequently than providers documented it in the EMR. Agreement between the patient survey and the EMR was poor for all 5A steps (kappa statistic = 0.01-0.22). Providers reported that they often or always performed each 5A action at a higher rate than indicated by EMR or patient report. However, providers who said they often or always performed individual 5A steps did not have consistently higher mean rates of EMR documentation or patient report than those who said they performed the 5A's less frequently. Little agreement was found among the three methods of measuring primary care providers' tobacco counseling actions. Implementing an EMR does not necessarily improve providers' documentation of tobacco interventions, but EMR adaptations that would standardize provider documentation of tobacco counseling might make the EMR a more reliable tool for monitoring providers' delivery of tobacco treatment services.