Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9)

Objective

To refine the Physician Documentation Quality Instrument (PDQI) and test the validity and reliability of the 9-item version (PDQI-9).

Methods

Three sets each of admission notes, progress notes and discharge summaries were evaluated by two groups of physicians using the PDQI-9 and an overall general assessment: one gold standard group consisting of program or assistant program directors (n = 7), and the other of attending physicians or chief residents (n = 24). The main measures were criterion-related validity (correlation coefficients between Total PDQI-9 scores and 1-item General Impression scores for each note), discriminant validity (comparison of PDQI-9 scores on notes rated as best and worst using 1-item General Impression score), internal consistency reliability (Cronbach’s alpha), and inter-rater reliability (intraclass correlation coefficient (ICC)).

Results

The results were criterion-related validity (r = –0.678 to 0.856), discriminant validity (best versus worst note, t = 9.3, p = 0.003), internal consistency reliability (Cronbach’s alphas = 0.87–0.94), and inter-rater reliability (ICC = 0.83, CI = 0.72–0.91).

Conclusion

The results support the criterion-related and discriminant validity, internal consistency reliability, and inter-rater reliability of the PDQI-9 for rating the quality of electronic physician notes. Tools for assessing note redundancy are required to complement use of PDQI-9. Trials of the PDQI-9 at other institutions, of different size, using different EHRs, and incorporating additional physician specialties and notes of other healthcare providers are needed to confirm its generalizability.     

Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital

Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children’s Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.     

Impact of a Statewide Trauma System on Rural Emergency Department Patient Assessment Documentation

Objective: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. Methods: A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O², and O² saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. Results: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in >1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. Conclusion: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.     

Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

Context

Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record.

Successful Implementation of Enhanced Recovery After Surgery Program in a Safety-Net Hospital: Barriers and Facilitators

PurposeEnhanced recovery after surgery (ERAS) programs comprise bundles of evidence-based recommendations designed to reduce physiological stress and support early return of function after surgery. In this study, we sought to investigate the barriers and facilitators of successful implementation of ERAS in a major safety-net hospital.DesignOur ERAS program has been designed as a quality improvement pilot project in prospective fashion with a real-time feedback loop. The program is designed to address established culture of safety-net hospitals.MethodsAn extensive multidisciplinary team investigated the barriers to success for three different levels of program stakeholders: providers, patients, and the facility. After a systematic review of these barriers, solutions were offered and implemented in a multidisciplinary care model with special attention to outcomes and continuous feedback. The findings are summarized in a grid format for better understanding and implementation ease.FindingsPatients (N = 198) were enrolled in an ERAS program in a nonrandomized fashion during the pilot period of October 2017 to August 2018. ERAS cohort of patients’ outcomes were then compared with those of 20,328 non-ERAS patients. The ERAS group had less complication with shorter length of stay compared with their non-ERAS counterparts. Furthermore, it has cost less to take care of these patients. Interestingly, this decrease was not achieved by a reciprocal increase in subsequent readmission or reoperation rates.ConclusionsUnique barriers exist when implementing an ERAS protocol in a safety-net hospital. These barriers can be overcome to improve the quality of care at a decreased cost. We have provided a grid to facilitate the implementation process.     

Where's the Beef? The Promise and the Reality of Clinical Documentation

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.     

A Nursing-Specific Model of EPR Documentation: Organizational and Professional Requirements

PURPOSE: To present the Norwegian documentation KPO model (quality assurance, problem solving, and caring). To present the requirements and multiple electronic patient record (EPR) functions the model is designed to address. METHODS: The model's professional substance, a conceptual framework for nursing practice is developed by examining, reorganizing, and completing existing frameworks. The model's methodology, an information management system, is developed using an expert group. Both model elements were clinically tested over a period of 1 year. RESULTS: The model is designed for nursing documentation in step with statutory, organizational, and professional requirements. Complete documentation is arranged for by incorporating the Nursing Minimum Data Set. A systematic and comprehensive documentation is arranged for by establishing categories as provided in the model's framework domains. Consistent documentation is arranged for by incorporating NANDA-I Nursing Diagnoses, Nursing Intervention Classification, and Nursing Outcome Classification. CONCLUSIONS: The model can be used as a tool in cooperation with vendors to ensure the interests of the nursing profession is met when developing EPR solutions in healthcare. Clinical RELEVANCE: The model can provide clinicians with a framework for documentation in step with legal and organizational requirements and at the same time retain the ability to record all aspects of clinical nursing.     

Developing a Successful Robotic Surgery Program in a Rural Hospital

Robotic surgery has become a standard in many large hospitals across the United States and the world. The surgical robot offers the surgeon a three-dimensional view and increased dexterity in addition to providing the benefits of laparoscopic surgery to the patient (eg, shorter hospital stays, decreased pain, fewer postoperative complications). The next progression for robotic surgery is a move to rural venues. For many small, rural hospitals, however, obtaining a robot may be cost prohibitive, and these facilities may need to explore sources of funding for the program. Developing a robotics program requires intense training by surgeons and all surgical team members. Effective marketing of the program and the dedication and hard work of surgical team members and administrators are vital to ensure the success of the program.