Introducing EHR Optimization in Clinical Documentation Processes

By January 6, 2016Blog

EHR optimization can be viewed in two ways. One is to simply look for redundancy in data input (e.g. asking the patient name) and eliminate those data entry recurrences. The second is more involved. True optimization of an EHR takes data redundancy, along with implementation of standards designed around process improvement, and applies these standards across all clinical processes in order to streamline human/machine interaction.

Investigating the Current Clinical Documentation State

It is best to first understand how the facility EHR system was initially configured. Obtaining some measure of understanding relative to the current state of documentation will prove helpful when addressing optimization.

To discover more about the current state of clinical documentation, ask the following questions:

  • Was clinical documentation simply a transfer of paper-based processes and customized to an electronic format?
  • Did the EHR vendor supply process templates or screens for customization by the customer?
  • Did nursing have a set of standards to work within when building clinical documentation?

These questions not only help to understand what barriers may exist from the EHR technology itself, but also provide some understanding of what level of organizational or cultural influences the future-state optimized condition will need to address.

Setting Optimization Standards

Introducing EHR optimization is best approached from a holistic perspective. That is a state where the standards, objectives and goals are managed and maintained throughout the entire optimization process.

A disciplined approach toward redefining a clinical workflow, as well as incorporating standards toward the input design screens themselves (often ignored) will result in measurable optimization.

Learn more about the benefits of EHR optimization for clinical documentation in the latest emids white paper.

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