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Electronic medical record customization and the impact upon chart completion rates.
Kevin J Bennett1, Christian Steen
1Department of Family and Preventive Medicine, University of South Carolina, SC, USA. kevin.bennett@sc.edu
Family Medicine
|May 13, 2010
Summary
Simple electronic medical record (EMR) template modifications improved clinical operations by increasing timely chart completion by nearly 5%. This enhances billing compliance and demonstrates the impact of inexpensive technological adjustments.
Area of Science:
- Health Informatics
- Clinical Operations Improvement
- Electronic Medical Record (EMR) Systems
Background:
- Clinical documentation timeliness is crucial for operational efficiency and revenue cycle management.
- Existing electronic medical record (EMR) systems may require optimization to meet evolving clinical documentation demands.
- Compliance policies often mandate timely chart completion for encounter billing.
Purpose of the Study:
- To evaluate the impact of modifying an existing EMR application's utility on clinical operations.
- To assess whether EMR template alterations can improve the efficiency of clinical documentation.
- To determine if changes to EMR usability enhance the rate of completed clinical encounters.
Main Methods:
- Modified disease-specific templates within an existing EMR application to centralize documentation and facilitate point-of-care input.
- Analyzed the time duration between chart entry creation and final signing for faculty providers.
- Focused on chart completion times to assess the impact of template modifications.
Main Results:
- Template modifications led to an approximate 5% increase in charts completed within the 30-day compliance window.
- The enhanced EMR documentation process resulted in a substantial increase in billable clinical encounters.
- Improved chart completion rates directly addressed compliance requirements for billing.
Conclusions:
- Simple, cost-effective modifications to existing EMR technology can significantly improve clinical operations.
- Optimizing EMR usability is a viable strategy for enhancing organizational efficiency and financial performance.
- The study highlights the importance of user-centered design in EMR applications for better clinical workflow management.
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