Tuesday, April 15, 2008

The Journey Towards Electronic Clinical Documentation

Over the past 3 years, we've been executing our Clinical Systems strategic plan to enhance clinical documentation, decision support, and data integration for all our care areas. Each of these deserves its own blog entry, and here's an overview of our clinical documentation efforts.

Over the past 5 years, we've used our self-built, web-based Online Medical Record, called webOMR for ambulatory care automation. By June 30, 2008, all outpatient clinical documentation must be done in webOMR to comply with medical staff bylaws as amended by the Medical Executive Committee. For those areas which require scanning of drawings, we're implementing an outpatient documentation scanning application using Fujitsu scanners and Captiva software, beginning in May.

Emergency Department
Our ED Dashboard is the workflow tool which drives all aspects of patient tracking and results display for the department. We're adding complete electronic documentation to this dashboard by this Summer through a combination templates/macros, structured forms and free text typing.

We've installed the Philips Compurecord Intraoperative charting application which includes automated interfaces to anesthesia machines, labs and all OR telemetry.

We've installed the iMDSoft Metavision charting application which includes automated interfaces to all ICU monitors, labs, and ventilators. We worked with iMDSoft to implement highly structured documentation which makes rounding and charting more accurate and efficient.

We're studying the right solution for the PACU now and we may implement iMDSoft there, ensuring one patient charting system is used for all perioperative management.

Ward Beds
We have a very comprehensive self-built Online Medical Record for all ambulatory encounters and we're enhancing it to support all clinical documentation on the wards. Here's the step by step implementation plan:

2007 - We implemented scanning of existing paper charts to provide a means of retiring our dependence on paper for medical record coding and historical review

2008 - By June, we'll go live with electronic History and Physicals which include a medication reconciliation function that is tightly linked to the outpatient record. The latter ensures medications will be tracked accurately as patients transition between inpatient and outpatient settings of care.

2009 - We'll expand our automated history and physicals charting applications to support daily inpatient progress notes. Once this is complete, we'll be able to integrate our self-built team census application with electronic charting to automate all signout processes. Automated signout processes will provide a means to document the responsible caregiver for the patient at all times.

2010 - Once all aspects of charting, signout, historical and physicals, operative notes, etc. are completed, we'll be able to create a highly detailed automated discharge summary. Today, we have a discharge document that is sent via the MA-Share infrastructure to the next provider of care and includes meds/problems/followup, but our next version will also incorporate all our electronic documentation features for a truly multidisciplinary continuity of care document for each patient.

By 2010, we will have reached the tipping point such that our need for paper documentation will have diminished and we can officially declare the electronic record as the official medical record. Today, we have a hybrid paper/electronic record during our transition state. Step by step we're on a logical journey toward clinical documentation and we're involving many clinicians, the HIM department and our governance committees in all our efforts.


Kim-Son said...

Thank you, Dr. Halamka, for the update. Let's hope that these improvements will reduce the mostly meaningless busywork that we interns engage on a daily basis, freeing us to spend more time doing what is truly important for the patients.

Matt said...

Lets hope though, that we all still take the time to do a thorough history and physical, as well as a good job writing our daily notes so are not just copying and pasting work done previously.

Chris Longhurst said...
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Chris Longhurst said...
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Chris Longhurst said...

One of the lessons from recent informatics literature seems to be that every health IT implementation can have unintended consequences. Some of these on the topic of clinical documentation are described by colleagues at BIDMC in the NEJM article "Off the Record — Avoiding the Pitfalls of Going Electronic". Your thoughts?

John Halamka said...

Next Tuesday's post will be about the Decision Support we've implemented that compliments Clinical Documentation. As Dr. Groopman has said, electronic documentation tools do not substitute for thinking!

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