Department of Nursing and Midwifery Informatics, Monash Health, Melbourne, Victoria, Australia.
School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Burwood, Melbourne, Victoria, Australia.
Appl Clin Inform. 2022 Aug;13(4):836-844. doi: 10.1055/s-0042-1756369. Epub 2022 Sep 7.
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.
Our objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation.
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.
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.
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.
在复杂的医疗环境中引入电子病历（EMR）系统从根本上改变了临床工作流程和文档处理方式，因此对患者安全有影响。在我们的大型公共医疗保健组织中进行了多站点“大爆炸”式 EMR 实施之后，开发并实施了一个质量改进计划，以监测临床医生的采用情况、文档质量以及与工作流程的合规性，以支持高质量的患者护理。
我们的目的是报告针对护理、助产和医疗 EMR 文档开发和实施迭代质量改进计划的情况。
改进模型（Model for Improvement）质量改进框架指导了“计划、执行、研究、行动”的循环。步骤包括设计、预测试和试点测试，以反映 EMR 文档的预期实践的审核工具，该工具检查了 EMR 实施 1 年后文档的质量和完整性。然后对初始审核结果进行分析，以（1）提供基准，以便对正在进行的改进进行基准比较，以及（2）开发针对性的干预活动，以解决已确定的差距。
作为 EMR 质量改进第一周期的基线，对 1349 次 EMR 记录审核的分析显示，护理和助产记录的九个组成部分中有五个，以及医疗记录的十个组成部分中的四个，其完成情况和质量被归类为良好（>80%）。这项工作的成果还包括一个用于改进 EMR 文档质量的策略框架，以及一个用于监测合规性的 EMR 数据仪表板。
这项工作为使用审核和反馈来制定质量监测框架提供了基础，为临床医生和 EMR 优化干预措施提供信息。绩效方面的学科差异可以为有针对性的干预措施提供信息，以最大限度地利用资源，并支持 EMR 文档和工作流程的纵向监测。未来的工作将包括重复进行 EMR 审核。
