Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review

Barriers and facilitators for using administrative data for surveillance purpose: A narrative overview

Although administrative data are not originally intended for surveillance purposes, they are frequently used for monitoring public health and patient safety. This article provides a narrative overview of the barriers and facilitators for the use of administrative data for surveillance, with a focus on healthcare-associated infection (HAI) in Canada. In this case, only articles on administrative data in general or related to HAI were included. Validation study and meta-analyses on administrative data accuracy were excluded. Medline, Embase and Google Scholar were searched as well as references list of all included articles, for a total of 90 articles included. Our analysis identifies 78 barriers at the individual, organizational and systemic levels and outlines 75 facilitators and solutions to improve administrative data utilization and quality. This narrative overview will help to understand barriers, facilitators and offer practical recommendations for optimizing the use of administrative data.

Paper-and-Pencil vs. Electronic Patient Records: Analyzing Time Efficiency, Personnel Requirements, and Usability Impacts on Healthcare Administration

Background: This study investigates the impact of transitioning from paper and pencil (P&P) methods to electronic patient records (EPR) on workflow and usability in surgical ward rounds. Methods: Surgical ward rounds were audited by two independent observers to evaluate the effects of transitioning from P&P to EPR. Key observations included the number of medical personnel and five critical workflow aspects before and after EPR implementation. Additionally, usability was assessed using the System Usability Scale (SUS) and the Post-Study System Usability Questionnaire (PSSUQ). Results: A total of 192 P&P and 160 EPR observations were analyzed. Physicians experienced increased administrative workload with EPR, while nurses adapted more easily. Ward teams typically consisted of two physicians and three or four nurses. Usability scores rated the system as "Not Acceptable" across all professional groups. Conclusions: The EPR system introduced usability challenges, particularly for physicians, despite potential benefits like improved data access. Usability flaws hindered system acceptance, highlighting the need for better workflow integration. Addressing these issues could improve efficiency and reduce administrative strain. As artificial intelligence becomes more integrated into clinical practice, healthcare professionals must critically assess AI-driven tools to ensure safe and effective patient care.

Differences in changes of data completeness after the implementation of an electronic medical record in three surgical departments of a German hospital-a longitudinal comparative document analysis

PURPOSE

The European health data space promises an efficient environment for research and policy-making. However, this data space is dependent on high data quality. The implementation of electronic medical record systems has a positive impact on data quality, but improvements are not consistent across empirical studies. This study aims to analyze differences in the changes of data quality and to discuss these against distinct stages of the electronic medical record's adoption process.

METHODS

Paper-based and electronic medical records from three surgical departments were compared, assessing changes in data quality after the implementation of an electronic medical record system. Data quality was operationalized as completeness of documentation. Ten information that must be documented in both record types (e.g. vital signs) were coded as 1 if they were documented, otherwise as 0. Chi-Square-Tests were used to compare percentage completeness of these ten information and t-tests to compare mean completeness per record type.

RESULTS

A total of N = 659 records were analyzed. Overall, the average completeness improved in the electronic medical record, with a change from 6.02 (SD = 1.88) to 7.2 (SD = 1.77). At the information level, eight information improved, one deteriorated and one remained unchanged. At the level of departments, changes in data quality show expected differences.

CONCLUSION

The study provides evidence that improvements in data quality could depend on the process how the electronic medical record is adopted in the affected department. Research is needed to further improve data quality through implementing new electronical medical record systems or updating existing ones.

Data Quality-Driven Improvement in Health Care: Systematic Literature Review

BACKGROUND

The promise of real-world evidence and the learning health care system primarily depends on access to high-quality data. Despite widespread awareness of the prevalence and potential impacts of poor data quality (DQ), best practices for its assessment and improvement are unknown.

OBJECTIVE

This review aims to investigate how existing research studies define, assess, and improve the quality of structured real-world health care data.

METHODS

A systematic literature search of studies in the English language was implemented in the Embase and PubMed databases to select studies that specifically aimed to measure and improve the quality of structured real-world data within any clinical setting. The time frame for the analysis was from January 1945 to June 2023. We standardized DQ concepts according to the Data Management Association (DAMA) DQ framework to enable comparison between studies. After screening and filtering by 2 independent authors, we identified 39 relevant articles reporting DQ improvement initiatives.

RESULTS

The studies were characterized by considerable heterogeneity in settings and approaches to DQ assessment and improvement. Affiliated institutions were from 18 different countries and 18 different health domains. DQ assessment methods were largely manual and targeted completeness and 1 other DQ dimension. Use of DQ frameworks was limited to the Weiskopf and Weng (3/6, 50%) or Kahn harmonized model (3/6, 50%). Use of standardized methodologies to design and implement quality improvement was lacking, but mainly included plan-do-study-act (PDSA) or define-measure-analyze-improve-control (DMAIC) cycles. Most studies reported DQ improvements using multiple interventions, which included either DQ reporting and personalized feedback (24/39, 61%), IT-related solutions (21/39, 54%), training (17/39, 44%), improvements in workflows (5/39, 13%), or data cleaning (3/39, 8%). Most studies reported improvements in DQ through a combination of these interventions. Statistical methods were used to determine significance of treatment effect (22/39, 56% times), but only 1 study implemented a randomized controlled study design. Variability in study designs, approaches to delivering interventions, and reporting DQ changes hindered a robust meta-analysis of treatment effects.

CONCLUSIONS

There is an urgent need for standardized guidelines in DQ improvement research to enable comparison and effective synthesis of lessons learned. Frameworks such as PDSA learning cycles and the DAMA DQ framework can facilitate this unmet need. In addition, DQ improvement studies can also benefit from prioritizing root cause analysis of DQ issues to ensure the most appropriate intervention is implemented, thereby ensuring long-term, sustainable improvement. Despite the rise in DQ improvement studies in the last decade, significant heterogeneity in methodologies and reporting remains a challenge. Adopting standardized frameworks for DQ assessment, analysis, and improvement can enhance the effectiveness, comparability, and generalizability of DQ improvement initiatives.

Educational interventions and their effects on healthcare professionals' digital competence development: A systematic review

INTRODUCTION

The digitalisation of healthcare requires that healthcare professionals are equipped with adequate digital competencies to be able to deliver high-quality healthcare. Continuing professional education is needed to ensure these competencies.

OBJECTIVE

This systematic review aimed to identify and describe the educational interventions that have been developed to improve various aspects of the digital competence of healthcare professionals and the effects of these interventions.

METHODS

A systematic literature review following the Joanna Briggs Institute's guidelines for Evidence Synthesis was conducted. Five electronic databases (CINAHL, PubMed, ProQuest, Scopus and Medic) up to November 2023 were searched for studies. Two researchers independently assessed the eligibility of the studies by title, abstract and full text and the methodological quality of the studies. Data tabulation and narrative synthesis analysis of study findings were performed. The PRISMA checklist guided the review process.

RESULTS

This review included 20 studies reporting heterogeneous educational interventions to develop the digital competence of healthcare professionals. The participants were mainly nurses and interventions were conducted in various healthcare settings. The length of the education varied from a 20-minute session to a six-month period. Education was offered through traditional contact teaching, using a blended-learning approach and through videoconference. Learning was enhanced through lectures, slide presentations, group work, case studies, discussions and practical exercises or simulations. Educational interventions achieved statistically significant results regarding participants' knowledge, skills, attitudes, perception of resources, self-efficacy or confidence and output quality.

CONCLUSIONS

The findings of this review suggest that digital competence education of nurses and allied health professionals would benefit from a multi-method approach. Training should provide knowledge as well as opportunities to interact with peers and instructors. Skills and confidence should be enhanced through practical training. Adequate organisational support, encouragement, and individual, needs-based guidance should be provided.

Enhancing Procedure Documentation in Neonatal Intensive Care Unit (NICU): A Quality Improvement Initiative at a Tertiary Neonatal Hospital

Background Accurate and comprehensive procedure documentation in Electronic Medical Records (EMR) is crucial for high-quality patient care, especially in high-acuity settings like Neonatal Intensive Care Units (NICU). Gaps in documentation at Corniche Hospital's NICU that were affecting patient safety and continuity of care were identified and addressed by following a pre and post-intervention design in the research. The process involved the initial audit, educational sessions with healthcare providers, and follow-up audits to measure improvements. Results post-intervention showed a significant increase in compliance with documentation standards, pointing out the effectiveness of educational interventions in improving EMR documentation practices. The local problem is demonstrated through the observation of incomplete and inconsistent procedure documentation in the NICU, hindering effective patient management and multi-disciplinary team communication. Methods A Quality Improvement Project (QIP) was implemented, including a baseline audit, educational interventions targeting healthcare providers, and subsequent re-audits to assess improvement. The project involved tailored educational sessions focused on correct EMR usage, adherence to documentation standards, and practical aspects of documenting procedures. Results Post-intervention, there was a significant increase in documentation compliance. The percentage of compliance in procedure encounter placement in EMR increased from 81% to 100%, and nursing documentation compliance improved from 11 (52.4%) to 18 (85.7%). However, a slight decrease in the completeness of physician documentation was noted. Conclusions The QIP effectively improved procedure documentation in the NICU. Continuous education and periodic review are essential for maintaining and further enhancing documentation standards. This initiative underscores the importance of targeted training and consistent audits in improving clinical documentation in healthcare settings.

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health System

BACKGROUND AND OBJECTIVE

 Clinical documentation is essential for conveying medical decision-making, communication between providers and patients, and capturing quality, billing, and regulatory measures during emergency department (ED) visits. Growing evidence suggests the benefits of note template standardization; however, variations in documentation practices are common. The primary objective of this study is to measure the utilization and coding performance of a standardized ED note template implemented across a nine-hospital health system.

METHODS

 This was a retrospective study before and after the implementation of a standardized ED note template. A multi-disciplinary group consensus was built around standardized note elements, provider note workflows within the electronic health record (EHR), and how to incorporate newly required medical decision-making elements. The primary outcomes measured included the proportion of ED visits using standardized note templates, and the distribution of billing codes in the 6 months before and after implementation.

RESULTS

 In the preimplementation period, a total of six legacy ED note templates were being used across nine EDs, with the most used template accounting for approximately 36% of ED visits. Marked variations in documentation elements were noted across six legacy templates. After the implementation, 82% of ED visits system-wide used a single standardized note template. Following implementation, we observed a 1% increase in the proportion of ED visits coded as highest acuity and an unchanged proportion coded as second highest acuity.

CONCLUSION

 We observed a greater than twofold increase in the use of a standardized ED note template across a nine-hospital health system in anticipation of the new 2023 coding guidelines. The development and utilization of a standardized note template format relied heavily on multi-disciplinary stakeholder engagement to inform design that worked for varied documentation practices within the EHR. After the implementation of a standardized note template, we observed better-than-anticipated coding performance.

The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis

BACKGROUND

Electronic medical records (EMR) are considered a key component of the health care system's digital transformation. The implementation of an EMR promises various improvements, for example, in the availability of information, coordination of care, or patient safety, and is required for big data analytics. To ensure those possibilities, the included documentation must be of high quality. In this matter, the most frequently described dimension of data quality is the completeness of documentation. In this regard, little is known about how and why the completeness of documentation might change after the implementation of an EMR.

OBJECTIVE

This study aims to compare the completeness of documentation in paper-based medical records and EMRs and to discuss the possible impact of an EMR on the completeness of documentation.

METHODS

A retrospective document analysis was conducted, comparing the completeness of paper-based medical records and EMRs. Data were collected before and after the implementation of an EMR on an orthopaedical ward in a German academic teaching hospital. The anonymized records represent all treated patients for a 3-week period each. Unpaired, 2-tailed t tests, chi-square tests, and relative risks were calculated to analyze and compare the mean completeness of the 2 record types in general and of 10 specific items in detail (blood pressure, body temperature, diagnosis, diet, excretions, height, pain, pulse, reanimation status, and weight). For this purpose, each of the 10 items received a dichotomous score of 1 if it was documented on the first day of patient care on the ward; otherwise, it was scored as 0.

RESULTS

The analysis consisted of 180 medical records. The average completeness was 6.25 (SD 2.15) out of 10 in the paper-based medical record, significantly rising to an average of 7.13 (SD 2.01) in the EMR (t178=-2.469; P=.01; d=-0.428). When looking at the significant changes of the 10 items in detail, the documentation of diet (P<.001), height (P<.001), and weight (P<.001) was more complete in the EMR, while the documentation of diagnosis (P<.001), excretions (P=.02), and pain (P=.008) was less complete in the EMR. The completeness remained unchanged for the documentation of pulse (P=.28), blood pressure (P=.47), body temperature (P=.497), and reanimation status (P=.73).

CONCLUSIONS

Implementing EMRs can influence the completeness of documentation, with a possible change in both increased and decreased completeness. However, the mechanisms that determine those changes are often neglected. There are mechanisms that might facilitate an improved completeness of documentation and could decrease or increase the staff's burden caused by documentation tasks. Research is needed to take advantage of these mechanisms and use them for mutual profit in the interests of all stakeholders.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023343; https://drks.de/search/de/trial/DRKS00023343.

The relationship between perceptions of electronic health record usability and clinical importance of social and environmental determinants of health on provider documentation

Social and environmental determinants of health (SEDH) data in the electronic health record (EHR) can be inaccurate and incomplete. Providers are in a unique position to impact this issue as they both obtain and enter this data, however, the variability in screening and documentation practices currently limits the ability to mobilize SEDH data for secondary uses. This study explores whether providers' perceptions of clinical importance of SEDH or EHR usability influenced data entry by analyzing two relationships: (1) provider charting behavior and clinical consideration of SEDH and (2) provider charting behavior and ease of EHR use in charting. We performed a cross-sectional study using an 11-question electronic survey to assess self-reported practices related to clinical consideration of SEDH elements, EHR usability and SEDH documentation of all staff physicians, identified using administrative listserves, at Penn State Health Hershey Medical Center during September to October 2021. A total of 201 physicians responded to and completed the survey out of a possible 2,478 identified staff physicians (8.1% response rate). A five-point Likert scale from "never" to "always" assessed charting behavior and clinical consideration. Responses were dichotomized as consistent/inconsistent and vital/not vital respectively. EHR usability was assessed as "yes" or "no" responses. Fisher's exact tests assessed the relationship between charting behavior and clinical consideration and to compare charting practices between different SEDHs. Cumulative measures were constructed for consistent charting and ease of charting. A generalized linear mixed model (GLMM) compared SDH and EDH with respect to each cumulative measure and was quantified using odds ratios (OR) and 95% confidence intervals (CI). Our results show that provider documentation frequency of an SEDH is associated with perceived clinical utility as well as ease of charting and that providers were more likely to consistently chart on SDH versus EDH. Nuances in these relationships did exist with one notable example comparing the results of smoking (SDH) to infectious disease outbreaks (EDH). Despite similar percentages of physicians reporting that both smoking and infectious disease outbreaks are vital to care, differences in charting consistency and ease of charting between these two were seen. Taken as a whole, our results suggest that SEDH quality optimization efforts cannot consider physician perceptions and EHR usability as siloed entities and that EHR design should not be the only target for intervention. The associations found in this study provide a starting point to understand the complexity in how clinical utility and EHR usability influence charting consistency of each SEDH element, however, further research is needed to understand how these relationships intersect at various levels in the SEDH data optimization process.

The unfulfilled promises of electronic health records

We provide a brief update on the current evidence on electronic health records' benefits, risks, and potential harms through a rapid narrative review. Many of the promised benefits of electronic health records have not yet been realised. Electronic health records are often not user-friendly. To enhance their potential, electronic health record platforms should be continuously evaluated and enhanced by carefully considering feedback from all stakeholders.

The Impact of Training on Electronic Health Records Related Knowledge, Practical Competencies, and Staff Satisfaction: A Pre-Post Intervention Study Among Wellness Center Providers in a Primary Health-Care Facility

Background

The transition to electronic health records (EHR) has improved the quality of health-care delivery and patient safety. However, poor usability and incongruent workflow may impose a significant burden on documentation and time management, resulting in staff burnout. We aimed to (i) evaluate the effectiveness of personalized EHR training on wellness providers' knowledge and practical competencies, and (ii) assess staff satisfaction regarding the EHR usage post-training.

Methodology

An interventional study was conducted between July 15, 2021, and March 1, 2022, among 14 wellness staff (age: 38 ± 3.9 years; 7 males, 7 females) in the Wellness Center-Rawdat Al-Khail Health Center. Six months of blended training was delivered. The impact of training was assessed using a pre-post survey on the knowledge and practical competencies related to EHR usage. Staff satisfaction was assessed post-training.

Results

Majority of respondents had improvement in identifying the advantages of EHR: improve confidentiality of care (pre = 35.7% vs post = 100%, p = 0.001), reduce medical errors (pre = 35.7% vs post = 85.7%, p = 0.02), improve quality of health care (pre = 35.7% vs post = 100%, p = 0.001), and reduce wait time (pre = 42.9% vs post = 85.7%, p = 0.03). Time performing these tasks by massage therapists/receptionists was reduced: viewing/editing ambulatory organizer (pre = 20±0 s vs post = 10±0 s), access PM office (pre = 155±136 s vs post = 10±0 s), selection/access patient chart (pre = 75±30 s vs post = 30±20 s), check-in/out (pre = 120±0 s vs post = 60±0 s), and view/edit massage form (pre = 135±75.5 s vs post = 60±0 s). For gym instructors, time to access ambulatory organizer (pre = 30±0 s vs post = 10±0 s), view/edit the gym form (pre = 101±57 s vs post = 71±36 s), view patients' clinical data (pre = 60±70 s vs post = 10±3 s), and place referral orders (pre = 197±144 vs post = 82±23 s) was reduced. A mean percentage score of 65.4±38.7 indicated very good staff satisfaction.

Conclusion

This tailored, hands-on training has been well received and effectively improved wellness staff knowledge, competencies, and satisfaction relative to EHR functionalities.

Effective and feasible interventions to improve structured EHR data registration and exchange: A concept mapping approach and exploration of practical examples in the Netherlands

BACKGROUND

Data in Electronic Health Records (EHRs) is often poorly structured and standardized, which hampers data reuse. Research described some examples of interventions to increase and improve structured and standardized data, such as guidelines and policies, training and user friendly EHR interfaces. However, little is known about the translation of this knowledge into practical solutions. Our study aimed to specify the most effective and feasible interventions that enable better structured and standardized EHR data registration and described practical examples of successfully implemented interventions.

METHODS

A concept mapping approach was used to determine feasible interventions that were considered to be effective or have been successfully implemented in Dutch hospitals. A focus group was held with Chief Medical Information Officers and Chief Nursing Information Officers. After interventions were determined, multidimensional scaling and cluster analysis were performed to categorize sorted interventions using Groupwisdom™, an online tool for concept mapping. Results are presented as Go-Zone plots and cluster maps. Following, semi-structured interviews were conducted to describe practical examples of successful interventions.

RESULTS

Interventions were classified into seven clusters ranked from highest to lowest perceived effectiveness: (1) education on usefulness and need; (2) strategic and (3) tactical organizational policies; (4) national policy; (5) monitoring and adjusting data (6) structure of and support from the EHR and (7) support in the registration process (EHR independent). Interviewees emphasized the following interventions proven successful in their practice: an enthusiastic ambassador per specialty who is responsible for educating peers by increasing awareness of the direct benefit of structured and standardized data registration; dashboards for continuous feedback on data quality; and EHR functionalities that support (automating) the registration process.

CONCLUSIONS

Our study provided a list of effective and feasible interventions including practical examples of interventions that have been successful. Organizations should continue to share their best practices to learn from and attempted interventions to prevent implementation of ineffective interventions.

Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: a Prospective Improvement Study

BACKGROUND

The introduction of electronic workflows has allowed for the flow of raw un-contextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete of clinically significant "signals". There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating.

OBJECTIVE

To describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation.

METHODS

This is a multi-hospital nonrandomized prospective improvement study conducted on the Inpatient General Internal Medicine Service across three hospital campuses at the New York University (NYU) Langone Health System. A group of physician leaders representing each campus met biweekly for six months. The output of these meetings included 1) a conceptualization of the note bloat problem as a dysfunction in information flow 2) a set of guiding principles for organizational documentation improvement 3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations and 4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience measured using the System Usability Scale (SUS). Primary outcomes measures after go-live include template utilization rate and note length in characters.

RESULTS

In usability testing amongst 22 medicine providers, the new progress note template averaged a usability score of 90.6/100 on the System Usability Scale. 77% of providers strongly agreed that the new template was easy to use. 68% strongly agreed that they would like to use the template frequently. In the three months after template implementation, General Internal Medicine providers wrote 65% of all inpatient notes with the new templates. During this period of time the organization saw a 46%, 47%, and 32% reduction in note length for general medicine progress notes, consults, and H&Ps, respectively, when compared to a baseline measurement period prior to interventions.

CONCLUSIONS

A bundled intervention that included deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency and patient outcomes.

CLINICALTRIAL

Automating Electronic Health Record Data Quality Assessment

Information systems such as Electronic Health Record (EHR) systems are susceptible to data quality (DQ) issues. Given the growing importance of EHR data, there is an increasing demand for strategies and tools to help ensure that available data are fit for use. However, developing reliable data quality assessment (DQA) tools necessary for guiding and evaluating improvement efforts has remained a fundamental challenge. This review examines the state of research on operationalising EHR DQA, mainly automated tooling, and highlights necessary considerations for future implementations. We reviewed 1841 articles from PubMed, Web of Science, and Scopus published between 2011 and 2021. 23 DQA programs deployed in real-world settings to assess EHR data quality (n = 14), and a few experimental prototypes (n = 9), were identified. Many of these programs investigate completeness (n = 15) and value conformance (n = 12) quality dimensions and are backed by knowledge items gathered from domain experts (n = 9), literature reviews and existing DQ measurements (n = 3). A few DQA programs also explore the feasibility of using data-driven techniques to assess EHR data quality automatically. Overall, the automation of EHR DQA is gaining traction, but current efforts are fragmented and not backed by relevant theory. Existing programs also vary in scope, type of data supported, and how measurements are sourced. There is a need to standardise programs for assessing EHR data quality, as current evidence suggests their quality may be unknown.

Improving the Efficiency of Medication Reconciliation in Two Taiwanese Hospitals by Using the Taiwan National Health Insurance PharmaCloud Medication System

Purpose

Medication reconciliation (MedRec) is a process to ensure complete and accurate communication of patient medication information throughout care transitions to prevent medication errors. Hospitals in Taiwan have stride to implement a universal protocol for MedRec. To establish a feasible protocol indigenously, the World Health Organization (WHO) protocol was incorporated with the Taiwan National Health Insurance (NHI) PharmaCloud patient medication profile. The efficiency and error detection capability of this modified protocol was evaluated in two hospitals.

Methods

A prospective, non-randomized, unblinded, multicenter cohort study was conducted. Subjects were recruited among patients admitted for colorectal or orthopedic surgery with at least 4 or more chronic drugs. To obtain the best possible medication history (BPMH), the control group was conducted according to the WHO protocol, and the experimental group used the modified WHO protocol with the medication data from the PharmaCloud system. The time spent on the two protocols was recorded. Admission and discharge orders were reconciled against the BPMH to identify any discrepancies. Discrepancies were evaluated by appropriateness, prescribing intentions, and types of inappropriateness. The levels of potential harm were classified for inappropriate discrepancies.

Results

The mean time to obtain BPMH in the control group was 34.3±10.8 minutes and in the experimental group 27.5±11.5 minutes (P = 0.01). The experimental group had more subjects with discrepancies (87.9%) than the control (58.3%) (p < 0.001). The discrepancies in both admission and discharge orders for the experimental group (84.5 and 67.2%) were higher than those of the control (47.9 and 37.5%). Many inappropriate discrepancies were classified as the potential harm of level 2 (77.8%).

Conclusion

Through the establishment of BPMH with the medication data from the Taiwan NHI PharmaCloud, MedRec could be achieved with greater efficiency and error detection capability in both the admission and discharge order validation processes.

Developing EMR-based algorithms to Identify hospital adverse events for health system performance evaluation and improvement: Study protocol

Background

Measurement of care quality and safety mainly relies on abstracted administrative data. However, it is well studied that administrative data-based adverse event (AE) detection methods are suboptimal due to lack of clinical information. Electronic medical records (EMR) have been widely implemented and contain detailed and comprehensive information regarding all aspects of patient care, offering a valuable complement to administrative data. Harnessing the rich clinical data in EMRs offers a unique opportunity to improve detection, identify possible risk factors of AE and enhance surveillance. However, the methodological tools for detection of AEs within EMR need to be developed and validated. The objectives of this study are to develop EMR-based AE algorithms from hospital EMR data and assess AE algorithm’s validity in Canadian EMR data.

Methods

Patient EMR structured and text data from acute care hospitals in Calgary, Alberta, Canada will be linked with discharge abstract data (DAD) between 2010 and 2020 (n~1.5 million). AE algorithms development. First, a comprehensive list of AEs will be generated through a systematic literature review and expert recommendations. Second, these AEs will be mapped to EMR free texts using Natural Language Processing (NLP) technologies. Finally, an expert panel will assess the clinical relevance of the developed NLP algorithms. AE algorithms validation: We will test the newly developed AE algorithms on 10,000 randomly selected EMRs between 2010 to 2020 from Calgary, Alberta. Trained reviewers will review the selected 10,000 EMR charts to identify AEs that had occurred during hospitalization. Performance indicators (e.g., sensitivity, specificity, positive predictive value, negative predictive value, F₁ score, etc.) of the developed AE algorithms will be assessed using chart review data as the reference standard.

Discussion

The results of this project can be widely implemented in EMR based healthcare system to accurately and timely detect in-hospital AEs.

Analysis on the completeness of case records of patients with penetrating ocular trauma following a multimodal intervention

Purpose

To describe the process development of a multimodal intervention and the pre- and postintervention results on the completeness of case records of patients with penetrating ocular trauma in a high-volume tertiary eye care hospital in south India.

Methods

A multimodal intervention including an objective-validated case sheet template, an education program, a physical template case record reminder, a continuous near-real time audit process, and a feedback system was developed. Analysis on the completeness of the case records of patients with ocular trauma from October 2020 to December 2020 (preintervention) and from January 2021 to March 2021 (postintervention) was performed. These case records and the personnel involved in the documentation, were given scores based on the scores assigned to the subsections of the validated template case sheet. The mean total score of the case records and of the personnel involved were analyzed.

Results

One hundred and eleven case records of patients with ocular trauma who underwent primary wound repair were included in the study. Of these 111 case records, 46 belonged to preintervention group and 65 belonged to postintervention group. The mean total score for preintervention group during the study period was 57.93 ± 24 out of 100 and for postintervention group was 99.07 ± 4.49 out of 100. The temporal trend of postintervention group showed a consistent improvement every month (97.14, 100,100) during the 3-month study period. Postintervention improvement was noted in all the sections of case records completed by both fellows and consultants.

Conclusion

A sustained improvement in ocular trauma case record documentation among all levels of medical professionals was noted following the five-component multimodal intervention.

Evaluation of an Electronic Medical Record Module for Nursing Documentation in Paediatric Palliative Care: Involvement of Nurses with a Think-Aloud Approach

BACKGROUND

Paediatric palliative care (PPC) is a noncurative approach to the care of children and adolescents with life-limiting and life-threatening illnesses. Electronic medical records (EMRs) play an important role in documenting such complex processes. Despite their benefits, they can introduce unintended consequences if future users are not involved in their development.

AIM

The aim of this study was to evaluate the acceptance of a novel module for nursing documentation by nurses working in the context of PPC.

METHODS

An observational study employing concurrent think-aloud and semi-structured qualitative interviews were conducted with 11 nurses working in PPC. Based on the main determinants of the unified theory of acceptance and use of technology (UTAUT), data were analysed using qualitative content analysis.

RESULTS

The main determinants of UTAUT were found to potentially influence acceptance of the novel module. Participants perceived the module to be self-explanatory and intuitive. Some adaptations, such as the reduction of fragmentation in the display, the optimization of confusing mouseover fields, and the use of familiar nursing terminology, are reasonable ways of increasing software adoption.

CONCLUSIONS

After adaptation of the modules based on the results, further evaluation with the participation of future users is required.

Electronic Medical Records for (Visceral) Medicine: An Overview of the Current Status and Prospects

Background

Electronic medical records (EMRs) offer key advantages over analog documentation in healthcare. In addition to providing details about current and past treatments, EMRs enable clear and traceable documentation regardless of the location. This supports evidence-based, multi-professional treatment and leads to more efficient healthcare. However, there are still several challenges regarding the use of EMRs. Understanding these challenges is essential to improve healthcare. The aim of this article is to provide an overview of the current state of EMRs in the field of visceral medicine, to describe the future prospects in this field, and to highlight some of the challenges that need to be faced.

Summary

The benefits of EMRs are manifold and particularly pronounced in the area of quality assurance and improvement of communication not only between different healthcare professionals but also between physicians and patients. Besides the danger of medical errors, the health consequences for the users (cognitive load) arise from poor usability or a system that does not fit into the real world. Involving users in the development of EMRs in the sense of participatory design can be helpful here. The use of EMRs in practice together with patients should be accompanied by training to ensure optimal outcomes in terms of shared decision-making.

Key Message

EMRs offer a variety of benefits. However, it is critical to consider user involvement, setting specificity, and user training during development, implementation, and use in order to minimize unintended consequences.

Participatory Design of a Medication Module in an Electronic Medical Record for Paediatric Palliative Care: A Think-Aloud Approach with Nurses and Physicians

BACKGROUND

Electronic medical records (EMRs) play a key role in improving documentation and quality of care in paediatric palliative care (PPC). Inadequate EMR design can cause incorrect prescription and administration of medications. Due to the fact of complex diseases and the resulting high level of medical complexity, patients in PPC are vulnerable to medication errors. Consequently, involving users in the development process is important. Therefore, the aim of this study was to evaluate the acceptance of a medication module from the perspective of potential users in PPC and to involve them in the development process.

METHODS

A qualitative observational study was conducted with 10 nurses and four physicians using a concurrent think-aloud protocol and semi-structured qualitative interviews. A qualitative content analysis was applied based on a unified theory of acceptance and use of technology.

RESULTS

Requirements from the user's perspective could be identified as possible influences on acceptance and actual use. Requirements were grouped into the categories "performance expectancies" and "effort expectancies".

CONCLUSIONS

The results serve as a basis for further development. Attention should be given to the reduction of display fragmentation, as it decreases cognitive load. Further approaches to evaluation should be taken.

Participatory Design of an Electronic Medical Record for Paediatric Palliative Care: A Think-Aloud Study with Nurses and Physicians

Background: Electronic medical records (EMRs) offer a promising approach to mapping and documenting the complex information gathered in paediatric palliative care (PPC). However, if they are not well developed, poorly implemented EMRs have unintended consequences that may cause harm to patients. One approach to preventing such harm is the involvement of users in the participatory design to ensure user acceptance and patient safety. Therefore, the aim of this study is to evaluate the acceptance of a novel patient chart module (PCM) as part of an EMR from the perspective of potential users in PPC and to involve these professionals in the design process. Methods: A qualitative observational study with N = 16 PPC professionals (n = 10 nurses, n = 6 physicians) was conducted, including concurrent think aloud (CTA) and semi-structured interviews. A structured content analysis based on the Unified Theory of Acceptance and Use of Technology was applied. Results: The results can be summarized in terms of general observations, performance expectancy, effort expectancy and facilitating conditions, all of which are likely to have a positive influence on acceptance of the PCM from the user perspective in the context of PPC. Conclusions: The involvement of users in the development of EMRs is important for meeting the requirements in PPC. Further software adaptations are necessary to implement these requirements.

Quality of the documentation of the Nursing process in clinical decision support systems

OBJECTIVE

to compare the quality of the Nursing process documentation in two versions of a clinical decision support system.

METHOD

a quantitative and quasi-experimental study of the before-and-after type. The instrument used to measure the quality of the records was the Brazilian version of the Quality of Diagnoses, Interventions and Outcomes, which has four domains and a maximum score of 58 points. A total of 81 records were evaluated in version I (pre-intervention), as well as 58 records in version II (post-intervention), and the scores obtained in the two applications were compared. The interventions consisted of planning, pilot implementation of version II of the system, training and monitoring of users. The data were analyzed in the R software, using descriptive and inferential statistics.

RESULTS

the mean obtained at the pre-intervention moment was 38.24 and, after the intervention, 46.35 points. There was evidence of statistical difference between the means of the pre- and post-intervention groups, since the p-value was below 0.001 in the four domains evaluated.

CONCLUSION

the quality of the documentation of the Nursing process in version II of the system was superior to version I. The efficacy of the system and the effectiveness of the interventions were verified. This study can contribute to the quality of documentation, care management, visibility of nursing actions and patient safety.

Impact of implementing structured note templates on data capture for hernia surgery

BACKGROUND

Electronic medical record notes have been determined to be lacking in quality, accessibility and content. Structured note templates could provide a way to improve these aspects, particularly with regard to data availability for research and quality improvement.

OBJECTIVE

To determine whether the implementation of a standardised template for hernia documentation can improve data completeness and timeliness.

METHOD

Retrospective review of clinic notes of 30 patients, 15 prior to implementation of a standardised note template and 15 after implementation of the template. The number of the 21 Americas Hernia Society Quality Collaborative (AHSQC) variables which were present in the notes was recorded, as was the time that the consultation ended and the time that the note was submitted.

RESULTS

Mean number of variables collected prior to implementation of the template was 5.9 ± 1.6 vs. 20 ± 0.4 after implementation (p < 0.001). In the pre-implementation group, 20% of the notes were completed after the day of the visit, while all of the notes in the post-implementation group were completed on the same day as the visit (p = 0.367).

CONCLUSION

Implementation of a structured note template resulted in significantly improved capture of specific database variables within clinical notes. Structured note templates are an effective tool to improve data capture from the clinical setting for research and quality improvement.

Social determinants of health in electronic health records and their impact on analysis and risk prediction: A systematic review

OBJECTIVE

This integrative review identifies and analyzes the extant literature to examine the integration of social determinants of health (SDoH) domains into electronic health records (EHRs), their impact on risk prediction, and the specific outcomes and SDoH domains that have been tracked.

MATERIALS AND METHODS

In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a literature search in the PubMed, CINAHL, Cochrane, EMBASE, and PsycINFO databases for English language studies published until March 2020 that examined SDoH domains in the context of EHRs.

RESULTS

Our search strategy identified 71 unique studies that are directly related to the research questions. 75% of the included studies were published since 2017, and 68% were U.S.-based. 79% of the reviewed articles integrated SDoH information from external data sources into EHRs, and the rest of them extracted SDoH information from unstructured clinical notes in the EHRs. We found that all but 1 study using external area-level SDoH data reported minimum contribution to performance improvement in the predictive models. In contrast, studies that incorporated individual-level SDoH data reported improved predictive performance of various outcomes such as service referrals, medication adherence, and risk of 30-day readmission. We also found little consensus on the SDoH measures used in the literature and current screening tools.

CONCLUSIONS

The literature provides early and rapidly growing evidence that integrating individual-level SDoH into EHRs can assist in risk assessment and predicting healthcare utilization and health outcomes, which further motivates efforts to collect and standardize patient-level SDoH information.

Pain Management in Clinical Practice Research Using Electronic Health Records

BACKGROUND

The use of electronic health record (EHR) systems encourages and facilitates the use of data for the development and surveillance of quality indicators, including pain management.

AIM

to conduct an integrative review on pain management research using data extracted from EHR in order to synthesize and analyze the following elements: pain management (assessments, interventions, and outcomes) and study results with potential clinical implications, data source, clinical sample characteristics, and method description.

DESIGN

An integrative review of the literature was undertaken to identify exemplars of scientific research studies that explore pain management using data from EHR, using Cooper's framework.

RESULTS

Our search of 1,061 records from PubMed, Scopus, and Cinahl was narrowed down to 28 eligible articles to be analyzed.

CONCLUSION

Results of this integrative review will make a critical contribution, assisting others in developing research proposals and sound research methods, as well as providing an overview of such studies over the past 10 years. Through this review it is therefore possible to guide new research on clinical pain management using EHR.

Behavior change techniques to promote healthcare professionals' eHealth competency: A systematic review of interventions

INTRODUCTION

The use of eHealth is rapidly -->increasing; however, many healthcare professionals have insufficient eHealth competency. Consequently, interventions addressing eHealth competency might be useful in fostering the effective use of eHealth.

OBJECTIVE

Our systematic review aimed to identify and evaluate the behavior change techniques applied in interventions to promote healthcare professionals' eHealth competency.

METHODS

We conducted a systematic literature review following the Joanna Briggs Institute's Manual for Evidence Synthesis. Published quantitative studies were identified through screening PubMed, Embase, and CINAHL. Two reviewers independently performed full-text and quality assessment. Eligible interventions were targeted to any healthcare professional and aimed at promoting eHealth capability or motivation. We synthesized the interventions narratively using the Behavior Change Technique Taxonomy v1 and the COM-B model.

RESULTS

This review included 32 studies reporting 34 heterogeneous interventions that incorporated 29 different behavior change techniques. The interventions were most likely to improve the capability to use eHealth and less likely to enhance motivation toward using eHealth. The promising techniques to promote both capability and motivation were action planning and participatory approach. Information about colleagues' approval, emotional social support, monitoring emotions, restructuring or adding objects to the environment, and credible source are techniques worth further investigation.

CONCLUSIONS

We found that interventions tended to focus on promoting capability, although motivation would be as crucial for competent eHealth performance. Our findings indicated that empathy, encouragement, and user-centered changes in the work environment could improve eHealth competency as a whole. Evidence-based techniques should be favored in the development of interventions, and further intervention research should focus on nurses and multifaceted competency required for using different eHealth systems and devices.