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EMRA/FERNE ED Documentation Session: How Can Electronic Records Help Improve Clinical Documentation?. Kevin M. Baumlin, MD Associate Professor & Director of Informatics Department of Emergency Medicine Mount Sinai School of Medicine New York, NY. Disclosures. Sunrise Solutions Group, Inc

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  1. EMRA/FERNE ED Documentation Session:How Can Electronic Records Help Improve Clinical Documentation?

  2. Kevin M. Baumlin, MD Associate Professor &Director of InformaticsDepartment of Emergency MedicineMount Sinai School of MedicineNew York, NY

  3. Disclosures • Sunrise Solutions Group, Inc • President, Founder • Healthcare IT and Process Improvement Solutions consulting group

  4. Why do we chart? • Document care given to a patient….

  5. Why do we chart? • Create a billing document • Communicate with other stakeholders care events • Protect our ____ • Medico- legal concerns

  6. The paper chart • Poor quality documentation • Prompts • None • (few or generic) • Difficult to & retrieve • Difficult to extract information (data) ?

  7. The Electronic Chart • High quality— • complete • Integrated decision support • Easy to store and retrieve • Ability to extract data

  8. How can electronic records help?-- quality clinical care • Documentation Templates • Integrated Decision support • Risk Management • Ask the correct questions • Regulatory Requirements • Guideline Adherence • Order Sets • Labs, rads and medications

  9. How about billing/coding? • Level of Service Calculators • End of documentation • As you go – Real time • Procedure templates • US… etc • Critical Care – the correct phrase….

  10. HPI Templates • ‘The ischemic stroke onset time has been confirmed in the following way, suggesting the three hour window for IV tPA has not expired’ • HPI templates- • Customize disease specific templates

  11. HPI Template Principles • Content enough for level 5 visit • All inclusive of clinical course of presenting complaint • Incorporate high risk data elements • Incorporate reminders and prompts to support clinical decision making • No hard stops– don’t torture docs!

  12. nudge

  13. Obtain the CT Quickly • ‘The ED staff and CT techs were informed that the CT for this patient had to be expedited because of the potential use of IV tPA’

  14. Sunshine– display data Display EM level on the Tracking Board

  15. Add the “phrases”-- nudge Customized Check Boxes

  16. Consents-- forms • Create forms printable from your EDIS- • Always available • Disease specific • Risk specific

  17. Conclusions Electronic Records can help Be involved Work with EDIS/IT teams to design what you need Sunshine– display- data Nudge Consolidate important information and prompt users to change behavior

  18. Questions? www.FERNE.org Kevin.baumlin@mssm.edu ferne_emra_2008_acep_ed_doc_baumlin_elect_record_102908_final

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