Enhancing problem list documentation in electronic health records using two methods: the example of prior splenectomy

Area of Science:

• Health Informatics
• Quality Improvement
• Clinical Documentation

Background:

• Quality improvement often involves choosing between patient-specific (e.g., clinical decision support - CDS) and population-based interventions (e.g., registries).
• This study addresses the challenge of accurate procedure documentation, specifically for patients with a history of splenectomy.

Purpose of the Study:

• To explore the synergistic potential of combining population health documentation (PHD) and CDS interventions.
• To enhance the documentation of splenectomy procedures within an electronic health record system.

Main Methods:

• Development of a population health documentation (PHD) intervention.
• Implementation of a clinical decision support (CDS) intervention.
• Measurement of splenectomy documentation rates before and after the interventions.

Main Results:

• Both PHD and CDS interventions significantly increased splenectomy documentation rates (p<0.001).
• The PHD intervention resulted in 444.7 documented splenectomies per month.
• The CDS intervention resulted in 40.8 documented splenectomies per month.

Conclusions:

• Both population health documentation and CDS interventions were effective in improving procedure documentation.
• The combined use of PHD and CDS strategies creates a symbiotic relationship, addressing existing documentation gaps and preventing future ones.
• Integrating these complementary strategies is recommended for optimizing health record completeness.