Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program

Abstract

Background Introducing an electronic medical record (EMR) system into a complex health care environment fundamentally changes clinical workflows and documentation processes and, hence, has implications for patient safety. After a multisite “big-bang” EMR implementation across our large public health care organization, a quality improvement program was developed and implemented to monitor clinician adoption, documentation quality, and compliance with workflows to support high-quality patient care. Objective Our objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation. Methods The Model for Improvement quality improvement framework guided cycles of “Plan, Do, Study, Act.” Steps included design, pre- and pilot testing of an audit tool to reflect expected practices for EMR documentation that examined quality and completeness of documentation 1-year post-EMR implementation. Analysis of initial audit results was then performed to (1) provide a baseline to benchmark comparison of ongoing improvement and (2) develop targeted intervention activities to address identified gaps. Results Analysis of 1,349 EMR record audits as a baseline for the first cycle of EMR quality improvement revealed five out of nine nursing and midwifery documentation components, and four out of ten medical documentation components' completion and quality were classified as good (>80%). Outputs from this work also included a framework for strategies to improve EMR documentation quality, as well as an EMR data dashboard to monitor compliance. Conclusion This work provides the foundation for the development of quality monitoring frameworks to inform both clinician and EMR optimization interventions using audits and feedback. Discipline-specific differences in performance can inform targeted interventions to maximize the effective use of resources and support longitudinal monitoring of EMR documentation and workflows. Future work will include repeat EMR auditing.

Workflow Improvement of Electronic Health Record Usage in a Tertiary Pediatric Burns Clinic

“…Similar studies have demonstrated improvements in workflow in other clinical settings, and support the need for ongoing QI and optimization programs for improved patient care. [9][10][11] The key to the improvements seen in this study stem from the close relationship between EHR interventions and clinical workflow. When collecting baseline data, detailed evaluation and analysis of clinician workflow, perceived inefficiencies, and user feedback were conducted.…”

Challenges of Data Quality in Clinical Data Life Cycle: A Systematic Review (Preprint)

“…We established the definitions for each clinical data life cycle stage by reviewing the literature (Table 2). The literature included in the review often describes the data life cycle for improving hospital EHR quality, quality measurement, and clinical decision support [29][30][31][32][33].…”

“…In our literature review, we found one commonality: all stages are interrelated and emphasize the need to manage data from a holistic, life cycle perspective [23]. The Plan-Do-Study-Act (PDSA) cycle, which was frequently mentioned in most of the articles we reviewed, is primarily used for short-term processes, such as data construction or operation [30,36,37]. Therefore, the PDSA cycle, which is mainly used in the data construction stage, could not be applied in our study.…”

“…Considering the characteristics among datasets, collecting data, and proceeding with overall data construction and management that reflects clinical attributes [29,36,[42][43][44][45][46][47] Operation stage Conducting data quality assessments on the constructed data and reviewing them from various angles and perspectives [29,30,42,48,49] Utilization Stage Sharing the outcomes of data quality validation, implementing data quality enhancement activities, and recalibrating the overall data quality [29,30,37,42]…”

Harnessing Electronic Medical Record Tools to Provide Proceduralist Feedback on Pediatric Endoscopy Quality Metrics

“…One benefit of having an EMR system that collects data on patient care is that this data can be collated and presented back to the user for action if needed. Accordingly, where available, EMR data dashboards have been used to provide feedback and track selected quality care indicators and metrics over time (3). Benefits of ongoing scheduled data collections and display include identification of care gaps for system response and assurance of continued adherence to and/or meeting of quality standards.…”