April 3, 2019 – Jaspreet Soor and Catherine Chater, VHA Home Healthcare – Electronic medical records (EMR) systems come with many advantages, however if not well-designed, they simply replicate duplication and unnecessary documentation practices from paper to EMR.
With documentation taking up a significant portion of the clinical time of health professionals, this area of EMR development is key in improving efficiency and gaining user buy-in during development and implementation of the EMR. Creating this additional time means increased direct client care time, improving health and quality of care outcomes for clients, while also improving the health professional’s well-being through a better work-life balance and work environment.
In developing the rehab EMR, documentation practices were comprehensively overhauled through the engagement of point of care occupational therapists, an audit of existing forms and continuous quality indicator testing. This led to innovative solutions in which best-practice clinical decision-making was incorporated into the charting process, improving the ease, efficiency and quality of charting. Using a lens of accuracy and precision, an evaluation of fields and even forms was conducted in defining items which served the purpose of required documentation standards and current scope of practice. By further adapting the documentation flow in the EMR to the real-life work flow of the occupational therapists, and including cues on best-practice guided clinical decision making, documentation volume was cut by up to 60%. The 90% voluntary uptake of the paper-based PDSA trials speaks to the success of these strategies in developing and implementing an EMR. Early survey and chart audit data shows a strong user satisfaction with a more consistent application of documentation and practice standards.
Effective clinical design of documentation (EMRI or paper-based) is of paramount importance to optimize use of limited health resources. Thoughtful examination of standards with clinical best practice and provider workflow, can positively impact both client outcome and provider job satisfaction.