Automating Inpatient Documentation

This year's IS Retreat focused on Acute Care Documentation and transforming inpatient wards into paperless workflows in support of our goal to have 85% of the BIDMC medical record automated by 2011.

Here are the minutes of our retreat, documenting our strategy for automating inpatient records.

1. A single point of entry for our built applications (or as few entry points as possible) would be ideal. The challenge is making this single point of entry default by person or location such that the entry view would be the inpatient dashboard, provider schedule, Emergency Department dashboard, or patient name lookup.

2. Having our departmental systems such as Anesthesia Information Management, Cardiology/EP, Metavision ICU Management, and Gcare Endoscopy documentation generate a PDF or summary accessible in one place would be ideal. Doctors will know that all the reports they need will be in one place, including highlights or abstracts of key information to speed the decision-making where possible.

3. Workflow analysis is important and should be completed before applications are coded. In FY09, Healthcare Quality will do the workflow analysis for "Who's the Caregiver", so that the first clinicial to call 24x7x365 is known for every patient. IS will do the workflow analysis on discharge worksheets with an eye toward smaller, short term enhancements in FY09 and more extensive redesign at a later point. Operations impact analysis should also accompany planned implementation. For example, electronic medication administration records may have capital needs such as bedside scanning. Operational and capital budgets should be approved and synchronized.

4. The discharge summary needs a comprehensive multi-stakeholder inventory. This needs assessment and policy should be done by the HIM committee. Once it is complete we can determine which data elements should flow from existing data sources and which should be entered by the clinician to achieve a "cognitive" overview of the patient's care.

5. Scanning should be used for charts/graphs/forms which are challenging to automate. Some forms, such as the medication administration record, have high clinical value and comprise a significant part of the record. Development of Medication Administration Record automation will begin in FY09 as part of our self built applications.

6. A problem oriented medical record requires histories/physicals and progress notes that include a robust community-wide vocabulary controlled problem list as part of their documentation design. These applications will be built rather than bought and will incorporate text entry/templates/macros. Introduction of controlled vocabularies for problem lists will be done via a phased, incremental approach. Team Census will be enhanced to become the daily documentation tool for progress notes.

7. Certain guiding principles should be included in our build and buy implementations - multidisciplinary, integrated, non-repudiatable, secure and web-based where possible.

8. Decisions between homegrown or vended products should consider the specific demands of an individual application and also the downstream impact of vended systems for other providers. Whenever possible we should use our existing applications.

9. Policies are needed to compliment our software rollouts. The HIM committee will suggest the policies and we will work together with the MEC to formalize policies and performance metrics as rollouts occur

10. We will review our plans with all our governance committees and stakeholders to ensure buy in for our approach.