- Email: [email protected]
280 Improved Documentation and Coding Utilizing Technological Reminders Within the Electronic Medical Record
Research Forum Abstracts results in 20 minutes or less and time to chest x-ray (CXR) in 30 minutes or less. The secondary outcomes were the overall percentages of compliance with post-intubation chest x-rays, blood gases, analgesia and sedation drips. Proportions were analyzed with Pearson’s Chi Squared modeling with multivariate logistic regression. Results: There were 285 patients included in the study, 118 prior to the implementation of the OS and 167 after. The median age and sex of the groups before and after were 63 years (range 1-99) (43% male) and 65 years (range 1-97) (48% male) respectively (P ¼ .469). The percentage of patients with a documented blood gas within 20 minutes before and after the OS implementation were 11.2% and 24.2%, respectively for an absolute difference of 13% (P ¼ .018), odds ratio ¼ 2.52 (P ¼ .02). Multivariate regression did not show an effect from age, sex, and the presence of CXR, analgesia or sedative. The percentage of patients with a documented CXR within 30 minutes before and after OS implementation were 36.0% vs 37.9% respectively with an absolute difference of 1.9% (P ¼ .756), There was no statistical difference in the secondary outcomes before and after the OS implementation; however, initiation of analgesia or sedation drip approached statistical significance (61.0% before vs 68.9% after, difference 7.9% [P ¼ .129]). Conclusion: The implementation of an electronic intubation order set resulted in only moderate improvement in compliance with standard post-intubation practices. We observed an increase in blood gases resulted within 20 minutes, although compliance was still low. Compliance with CXR and initiation of analgesia or sedation infusion remained low, even after the intervention. There is still a great deal of room for improvement in patient care after intubation in the ED. Further studies should evaluate additional factors that could lead to improved compliance with expected post-intubation care.
280
Improved Documentation and Coding Utilizing Technological Reminders Within the Electronic Medical Record
Podolsky S, Blaha S, Fertel BS/Cleveland Clinic, Cleveland, OH
Study Objectives: In busy emergency departments (ED) physicians may forget to document all of their work. This incomplete documentation may unintentionally underestimate work effort, decrease communication of important care processes or clinical problems, and create potential for lost revenue (as charts are down coded when certain essential elements are missing). Examples include patients placed in ED clinical decision units (CDU), as well as patients admitted to intensive care units (ICU). In the CDU, charts often need a documented family history to achieve maximum evaluation and management (E&M) levels. For patients admitted to the ICU, clinical encounters often meet criteria for critical care billing, though without necessary documentation cannot be billed appropriately. In order to fully capture reimbursement of work completed, we sought to improve documentation and compliance using two interventions: data transparency and technological reminders. Methods: We conducted a multicenter, interventional study to evaluate whether data transparency and technological reminders in the electronic medical record (EMR) would improve chart documentation. The study was conducted in three ED: one large, academic medical center and two community practice settings and included 65 emergency physicians. There were two main outcomes measured: (1) documentation of a family history for patients entering an ED CDU and (2) documentation of critical care billing for patients admitted to an ICU. The first intervention involved data transparency via a monthly e-mail to all physicians that included a list of all physician names and the associated number of down-coded charts. The second intervention was a real-time EMR alert that fired to the physician if either of the following scenarios existed: a family history was inadvertently omitted from the patient chart at the time of admission to a CDU, or if critical care was not documented at the time of admission to an ICU. (In the latter case, the question was posed as to the appropriateness of critical care time.) Neither alert forced a provider to enter data. We performed a Chi-square test to compare proportions pre and post intervention. Results: Pre-intervention data showed that of patients placed in our CDU, 37 of 455 charts (8.1%) were missing a family history. Post-intervention data showed that of patients placed in our CDU, 337 of 6,946 charts (4.8%) were missing a family history, a relative reduction of 37.5% (8.1% vs 4.8%, or an absolute reduction of 3.3%, chisquare test, P < .05). This trend continued to lower. For patients admitted to an ICU, 33 of 159 charts (21%) were missing critical care documentation. Post-intervention
Volume 66, no. 4s : October 2015
data showed that for patients admitted to an ICU, 214 of 1836 charts (11.6%) were missing critical care documentation, a relative reduction of 45% (21% vs 11.6%, or an absolute reduction of 9.4%, chi-square test, P < .05). Conclusion: Data transparency and physician reminders were highly effective in changing physician behavior related to documentation compliance. These simple interventions improved communication of important care processes or clinical problems and also reduced lost revenue.
281
Integrating Environmental Data into a Personal Health Record for Asthma Patients
Killeen JP, Chan TC, Castillo EM, Grisworld WG/University of California, San Diego, San Diego, CA
Study Objectives: Data and systems that support patient empowerment through health information technology (IT) have become increasingly available in recent years and are becoming important for managing acute conditions such as asthma. The objective of this pilot project was to test and demonstrate secure and reliable transmission of real-time patient and environmental data between end-users of National Association for Trusted Exchange (NATE) community health information service Providers (HISPs) and patient-owned personal health records. Our use cases focused on the transport of data for patients with acute asthma. Methods: This was a prospective one-month pilot study that incorporated existing applications to securely transmit data between a personal health device, environmental sensors, personal health records (PHR), community health information exchange (HIE) and a hospital system electronic medical record (EMR) for asthma patients. Data were incorporated in a continuity of care document (CCD) including the patient’s medications, allergies, problem list, and encounter data. The PHR (Microsoft HealthVault) consumed and displayed the CCD data in a patient-friendly format. A direct message (federal standard) account was established for the patient and connected with the provider’s account within a regional HIE. Study asthma patients extracted their CCD allowing for an open interoperability with personal devices and Microsoft Azure for analytics. Study subjects were provided with a MDI geolocation counter with their inhaler (PropellerHealth tracking inhaler use and location) and an innovative hand-held air quality monitor (measuring ozone, carbon monoxide, nitrogen dioxide levels), and real-time data recorded and paired to the patient’s smartphone and transmitted as secure discrete data. The summary of MDI utilization included the number of times it was used and the geolocation. This data and air quality data were displayed on the smart phone as well as secure Web site for the patient. Data elements were transmitted to an account within Microsoft Azure cloud for analytic summary reports. Reports were automatically transmitted to the PHR (Microsoft HealthVault) and to the patient’s EMR (EPIC). Providers were able to view the data via the EMR. Results: During the pilot period of January 1, 2013 to February 1, 2013, five asthma patients were selected to carry both the air quality and counter MDI device. During the time period, each subject used the MDI daily multiple times and location, time and frequency were tracked. Air quality was transmitted every 6 seconds to the database. Overall, 3 megabits of raw data were transmitted securely per study subject per day. Patients viewed their data on a daily and weekly basis. Summary data were generated daily and transmitted to the PHR. All study subjects sent the PHR report to the EMR for view by the provider via direct messaging. All 5 patients and 2 providers were satisfied with data reports without receiving the raw data. Conclusion: This pilot demonstrated the ability for real-time MDI and environmental tracking data to be collected by the patient and sent to the provider EMR through a PHR and NATE-certified HISPs. A larger, longitudinal study is needed to confirm these findings and determine their impact on health behaviors and outcome.
282
NESTED: National Trauma Registry Study of Deprivation
Corfield A, Pell J, MacKay D/Royal Alexandra Hospital, Paisley, United Kingdom; Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
Background: Trauma remains a leading cause of morbidity and mortality in the UK and throughout the world. Social deprivation has been linked with many types of ill health. Previous work has shown an association between social deprivation and
Annals of Emergency Medicine S101
280
Improved Documentation and Coding Utilizing Technological Reminders Within the Electronic Medical Record
Podolsky S, Blaha S, Fertel BS/Cleveland Clinic, Cleveland, OH
Study Objectives: In busy emergency departments (ED) physicians may forget to document all of their work. This incomplete documentation may unintentionally underestimate work effort, decrease communication of important care processes or clinical problems, and create potential for lost revenue (as charts are down coded when certain essential elements are missing). Examples include patients placed in ED clinical decision units (CDU), as well as patients admitted to intensive care units (ICU). In the CDU, charts often need a documented family history to achieve maximum evaluation and management (E&M) levels. For patients admitted to the ICU, clinical encounters often meet criteria for critical care billing, though without necessary documentation cannot be billed appropriately. In order to fully capture reimbursement of work completed, we sought to improve documentation and compliance using two interventions: data transparency and technological reminders. Methods: We conducted a multicenter, interventional study to evaluate whether data transparency and technological reminders in the electronic medical record (EMR) would improve chart documentation. The study was conducted in three ED: one large, academic medical center and two community practice settings and included 65 emergency physicians. There were two main outcomes measured: (1) documentation of a family history for patients entering an ED CDU and (2) documentation of critical care billing for patients admitted to an ICU. The first intervention involved data transparency via a monthly e-mail to all physicians that included a list of all physician names and the associated number of down-coded charts. The second intervention was a real-time EMR alert that fired to the physician if either of the following scenarios existed: a family history was inadvertently omitted from the patient chart at the time of admission to a CDU, or if critical care was not documented at the time of admission to an ICU. (In the latter case, the question was posed as to the appropriateness of critical care time.) Neither alert forced a provider to enter data. We performed a Chi-square test to compare proportions pre and post intervention. Results: Pre-intervention data showed that of patients placed in our CDU, 37 of 455 charts (8.1%) were missing a family history. Post-intervention data showed that of patients placed in our CDU, 337 of 6,946 charts (4.8%) were missing a family history, a relative reduction of 37.5% (8.1% vs 4.8%, or an absolute reduction of 3.3%, chisquare test, P < .05). This trend continued to lower. For patients admitted to an ICU, 33 of 159 charts (21%) were missing critical care documentation. Post-intervention
Volume 66, no. 4s : October 2015
data showed that for patients admitted to an ICU, 214 of 1836 charts (11.6%) were missing critical care documentation, a relative reduction of 45% (21% vs 11.6%, or an absolute reduction of 9.4%, chi-square test, P < .05). Conclusion: Data transparency and physician reminders were highly effective in changing physician behavior related to documentation compliance. These simple interventions improved communication of important care processes or clinical problems and also reduced lost revenue.
281
Integrating Environmental Data into a Personal Health Record for Asthma Patients
Killeen JP, Chan TC, Castillo EM, Grisworld WG/University of California, San Diego, San Diego, CA
Study Objectives: Data and systems that support patient empowerment through health information technology (IT) have become increasingly available in recent years and are becoming important for managing acute conditions such as asthma. The objective of this pilot project was to test and demonstrate secure and reliable transmission of real-time patient and environmental data between end-users of National Association for Trusted Exchange (NATE) community health information service Providers (HISPs) and patient-owned personal health records. Our use cases focused on the transport of data for patients with acute asthma. Methods: This was a prospective one-month pilot study that incorporated existing applications to securely transmit data between a personal health device, environmental sensors, personal health records (PHR), community health information exchange (HIE) and a hospital system electronic medical record (EMR) for asthma patients. Data were incorporated in a continuity of care document (CCD) including the patient’s medications, allergies, problem list, and encounter data. The PHR (Microsoft HealthVault) consumed and displayed the CCD data in a patient-friendly format. A direct message (federal standard) account was established for the patient and connected with the provider’s account within a regional HIE. Study asthma patients extracted their CCD allowing for an open interoperability with personal devices and Microsoft Azure for analytics. Study subjects were provided with a MDI geolocation counter with their inhaler (PropellerHealth tracking inhaler use and location) and an innovative hand-held air quality monitor (measuring ozone, carbon monoxide, nitrogen dioxide levels), and real-time data recorded and paired to the patient’s smartphone and transmitted as secure discrete data. The summary of MDI utilization included the number of times it was used and the geolocation. This data and air quality data were displayed on the smart phone as well as secure Web site for the patient. Data elements were transmitted to an account within Microsoft Azure cloud for analytic summary reports. Reports were automatically transmitted to the PHR (Microsoft HealthVault) and to the patient’s EMR (EPIC). Providers were able to view the data via the EMR. Results: During the pilot period of January 1, 2013 to February 1, 2013, five asthma patients were selected to carry both the air quality and counter MDI device. During the time period, each subject used the MDI daily multiple times and location, time and frequency were tracked. Air quality was transmitted every 6 seconds to the database. Overall, 3 megabits of raw data were transmitted securely per study subject per day. Patients viewed their data on a daily and weekly basis. Summary data were generated daily and transmitted to the PHR. All study subjects sent the PHR report to the EMR for view by the provider via direct messaging. All 5 patients and 2 providers were satisfied with data reports without receiving the raw data. Conclusion: This pilot demonstrated the ability for real-time MDI and environmental tracking data to be collected by the patient and sent to the provider EMR through a PHR and NATE-certified HISPs. A larger, longitudinal study is needed to confirm these findings and determine their impact on health behaviors and outcome.
282
NESTED: National Trauma Registry Study of Deprivation
Corfield A, Pell J, MacKay D/Royal Alexandra Hospital, Paisley, United Kingdom; Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
Background: Trauma remains a leading cause of morbidity and mortality in the UK and throughout the world. Social deprivation has been linked with many types of ill health. Previous work has shown an association between social deprivation and
Annals of Emergency Medicine S101