Electronic medical record customization and the impact upon chart completion rates

Department of Family and Preventive Medicine, University of South Carolina, SC, USA.
Family medicine (Impact Factor: 1.17). 05/2010; 42(5):338-42.
Source: PubMed


The study's objective was to determine if alterations to the utility of an existing electronic medical record (EMR) application resulted in an improvement in clinical operations.
We altered several templates within an existing EMR application to improve ease of documentation of clinical encounters. These changes were disease specific, brought documentation into central locations, and altered the input method to facilitate point of care documentation. We examined the length of time (in days) from the creation of a chart entry to the final signing of that chart entry. These charts were delimited to faculty providers who had an active clinical practice during the entire study period.
We discovered that the template changes resulted in an increase in the number of charts completed within 30 days by nearly 5%, resulting in a substantial number of billable clinical encounters.
This improvement is important, as compliance policies prohibit the billing of encounters if the chart is not completed within 30 days. We conclude that simple, inexpensive changes in existing technology may be adequate to have a significant impact upon an organization.

Download full-text


Available from: Kevin J. Bennett, Oct 10, 2015
12 Reads
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) has been designated as the recommended clinical reference terminology for use in clinical information systems around the world and is reported to be used in over 50 countries. However, there are still few implementation details. This study examined the implementation of SNOMED CT in terms of design, use and maintenance issues involved in 13 healthcare organisations across eight countries through a series of interviews with 14 individuals. While a great deal of effort has been spent on developing and refining SNOMED CT, there is still much work ahead to bring SNOMED CT into routine clinical use.
    Journal of Biomedical Informatics 10/2012; 46(1). DOI:10.1016/j.jbi.2012.09.006 · 2.19 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Since 2004, increasing importance has been placed on the adoption of electronic medical records by healthcare providers for documentation of patient care. Recent federal regulations have shifted the focus from adoption alone to meaningful use of an electronic medical record system. As proposed by the Technology Acceptance Model, the behavioral intention to use technology is determined by the person's attitude toward usage. The purpose of this quality improvement project was to devise and implement customized templates into an existent electronic medical record system in a single clinic and measure the satisfaction of the clinic providers with the system before and after implementation. Provider satisfaction with the electronic medical record system was evaluated prior to and following template implementation using the current version 7.0 of the Questionnaire for User Interaction Satisfaction tool. Provider comments and improvement in the Questionnaire for User Interaction Satisfaction levels of rankings following template implementation indicated a positive perspective by the providers in regard to the templates and customization of the system.
    Computers, informatics, nursing: CIN 01/2013; 31(3). DOI:10.1097/NXN.0b013e3182771814 · 0.72 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To examine the concordance between parent report and electronic medical record documentation of asthma health education provided during a single clinic visit and second-hand tobacco smoke exposure among children with asthma. Methods: Parents of children with asthma were recruited from two types of clinics using different electronic medical record systems: asthma-specialty or general pediatric health department clinics. After their child's outpatient visit, parents were interviewed by trained study staff. Interview data were compared to electronic medical records for agreement in five categories of asthma health education and for the child's environmental tobacco smoke exposure. Kappa statistics were used to identify strength of agreement. Chi square and t-tests were used to examine differences between clinic types. Results: Of 255 parents participating in the study 90.6% were African American and 96.1% were female. Agreement was poor across all clinics but was higher within the asthma specialty clinics than the health department clinics for smoke exposure (κ = 0.410 versus 0.205), asthma diagnosis/disease process (κ = 0.213 versus -0.016) and devices reviewed (κ = 0.253 versus -0.089) with parents generally reporting more education provided. For the 203 children with complete medical records, 40.5% did not have any documentation regarding smoking exposure in the home and 85.2% did not have any documentation regarding exposure elsewhere. Conclusions: We found low concordance between the parent's report and the electronic medical record for smoke exposure and asthma education provided. Un- or under-documented smoke exposure and health education have the potential to affect continuity of care for pediatric patients with asthma.
    Journal of Asthma 07/2013; 50(9). DOI:10.3109/02770903.2013.828303 · 1.80 Impact Factor