Justin Iannello1, Nida Waheed1, Patrick Neilan1. 1. is National Lead Physician Utilization Management Advisor for the Veterans Health Administration and Associate Chief of Staff for Clinical Informatics at the Southeast Louisiana Veterans Health Care System in New Orleans. is Chief Resident in Quality and Patient Safety for the Department of Internal Medicine, and is Chief Resident for the Department of Internal Medicine, both at University of Florida in Gainesville.
Abstract
BACKGROUND: Electronic health record templates have served a variety of functions, such as improving documentation for reliable reporting of health care outcomes. Standardizing template documentation has been important for accurately capturing case workload and supporting quality improvement initiatives. METHODS: North Florida/South Georgia Veterans Health System consists of 2 Florida-based hospitals: Malcom Randall Veterans Affairs Medical Center (MRVAMC) in Gainesville, and Lake City Veterans Affairs Medical Center (LCVAMC). In the first quarter of fiscal year 2017, MRVAMC and LCVAMC had a below-average case severity index (CSI) of 0.76 and 0.81, respectively, compared with that of the 0.96 national average for the Veterans Health Administration (VHA). An innovative history and physical template design with embedded informatics tools was created to improve clinical documentation. RESULTS: Compliance with standardized history and physical medicine template use was monitored for about 1 year after standardized template implementation. Compliance improved from 43.2% in June 2018 to 89.9% in June 2019 at MRVAMC and increased from 48.2% in June 2018 to 96.9% in June 2019 at LCVAMC. CSI improved to 0.97 at MRVAMC and 1.07 at LCVAMC in the first quarter of fiscal year 2019, which exceeded the VHA national average of 0.89 during the same period. CONCLUSIONS: NF/SGVHS integrated informatics solutions within template design was associated with an increase in CSI via improved clinical documentation.
BACKGROUND: Electronic health record templates have served a variety of functions, such as improving documentation for reliable reporting of health care outcomes. Standardizing template documentation has been important for accurately capturing case workload and supporting quality improvement initiatives. METHODS: North Florida/South Georgia Veterans Health System consists of 2 Florida-based hospitals: Malcom Randall Veterans Affairs Medical Center (MRVAMC) in Gainesville, and Lake City Veterans Affairs Medical Center (LCVAMC). In the first quarter of fiscal year 2017, MRVAMC and LCVAMC had a below-average case severity index (CSI) of 0.76 and 0.81, respectively, compared with that of the 0.96 national average for the Veterans Health Administration (VHA). An innovative history and physical template design with embedded informatics tools was created to improve clinical documentation. RESULTS: Compliance with standardized history and physical medicine template use was monitored for about 1 year after standardized template implementation. Compliance improved from 43.2% in June 2018 to 89.9% in June 2019 at MRVAMC and increased from 48.2% in June 2018 to 96.9% in June 2019 at LCVAMC. CSI improved to 0.97 at MRVAMC and 1.07 at LCVAMC in the first quarter of fiscal year 2019, which exceeded the VHA national average of 0.89 during the same period. CONCLUSIONS: NF/SGVHS integrated informatics solutions within template design was associated with an increase in CSI via improved clinical documentation.
Authors: Eric L Grogan; Theodore Speroff; Stephen A Deppen; Christianne L Roumie; Tom A Elasy; Robert S Dittus; S Trent Rosenbloom; Michael D Holzman Journal: J Am Coll Surg Date: 2004-09 Impact factor: 6.113
Authors: Vidhu V Thaker; Felix Lee; Clement J Bottino; Cassandra L Perry; Ingrid A Holm; Joel N Hirschhorn; Stavroula K Osganian Journal: Clin Pediatr (Phila) Date: 2015-12-15 Impact factor: 1.168