Template Design and Analysis: Integrating Informatics Solutions to Improve Clinical Documentation

Area of Science:

• Health Informatics
• Clinical Documentation Improvement
• Healthcare Quality Management

Background:

• Electronic health record (EHR) templates are crucial for reliable health care outcome reporting and quality improvement.
• Standardized documentation in EHR templates aids in accurate case workload capture and supports quality initiatives.

Purpose of the Study:

• To evaluate the impact of an innovative EHR history and physical template with embedded informatics tools on clinical documentation and case severity index (CSI).

Main Methods:

• The North Florida/South Georgia Veterans Health System implemented a new EHR template design with informatics tools at two hospitals.
• Compliance with the new template was monitored for one year post-implementation.
• Case Severity Index (CSI) was tracked before and after the implementation.

Main Results:

• Template compliance increased significantly, from 43.2% to 89.9% at MRVAMC and 48.2% to 96.9% at LCVAMC.
• The CSI improved at both MRVAMC (from 0.76 to 0.97) and LCVAMC (from 0.81 to 1.07), surpassing the national Veterans Health Administration (VHA) average.

Conclusions:

• Integrating informatics solutions into EHR template design was associated with improved clinical documentation.
• This improvement in documentation led to a notable increase in the Case Severity Index (CSI) at the participating VHA facilities.