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Patient Safety and Quality Reporting: How an EMR Can Help
The ASC industry has certainly been proactive in many ways. Several organizations are working on defining consensus measures of safety and quality in order to make the reporting task both meaningful and manageable. The ASC Quality Collaboration, a group comprised of many industry leaders, has promulgated five key quality measures which have been endorsed by the National Quality Forum. At the same time, the Joint Commission has defined a core set of ambulatory patient safety goals.
Responding to this heightened emphasis on quality reporting will not be easy. Essentially an ASC has three options today.
1. Rely on manual abstraction from paper charts and records. Not only is this approach costly and time-consuming, but it also poses scalability challenges as reporting requirements continue to mount.
2. Rely on financial and administrative software systems currently in place. This solution provides a certain degree of electronic data access, mitigating the human abstracting problem. But the limitations can make this choice less optimal. First, most systems in use are legacy in nature with significant gaps in types and quantities of relevant information that can be input. Moreover, they are generally not designed to capture routinely and rigorously the range of clinical data needed to track patient safety and quality adequately.
3. Adopt an electronic medical record (EMR) solution fully integrated with a management system. Today’s EMRs bring automation to the clinical information side of the equation, thereby directly addressing the data most needed to analyze and report on quality. An EMR goes well beyond the documentation typically found in a case history tool in a management system and automatically creates rich structured data rather than narrative, allowing robust and flexible analysis and reporting – both immediately and over time.
It is important to note that the best EMR systems aid quality initiatives not only by permitting effective and efficient post-facto reporting but also by promoting safety and best practices before, during and after surgery. A good EMR helps embed care quality in the fabric of the organization.
To illustrate just how directly an EMR designed for the ASC environment fosters quality and permits ease of reporting, here is a small sample of relevant EMR features for each of the five measures recommended by the ASC Quality Collaboration.
ASC Quality Collaboration Measures
1. Patient burn — To capture the number of admissions (patients) who experience a burn prior to discharge.
- Calculation and presentation onscreen of normal thermia measures.
- Electronic documentation of alcohol-based preoperative procedures creates structured data that can be searched and combined easily.
- Electronic documentation of steps taken to prevent burns creates structured data.
2. Prophylactic IV antibiotic timing — To capture whether antibiotics given for prevention of surgical site infection were administered on time.
- Automatic time calculators in the software for pre-op medications capture and display time administered v. procedure start time.
3. Patient falls in the ASC — To capture the number of admissions (patients) who experience a fall within the ASC.
- Risk-to-fall indicators calculate a risk score based on patient information and display the score prominently.
4. Wrong site, wrong side, wrong patient, wrong procedure, wrong implant — To capture any ASC admissions (patients) who experience a wrong site, side, patient, procedure or implant.
- Time-out calculator.
- Features that permit documentation of patient marking.
5. Hospital ransfer/Admission
- Specific fields capture electronic documentation of transfer events.
Compliance with Joint Commission standards is another overriding concern of ASCs, and automating processes and documentation in the clinical setting through an EMR can greatly improve ability to meet these goals. Here are five of the Joint Commission’s 2009 ambulatory goals and representative features in an EMR that can contribute to satisfying the corresponding goal.
Selected Joint Commission 2009 ambulatory patient safety goals
1. Improve the accuracy of patient identification
- Multiple patient identifiers, including picture, are constantly available and always displayed in the electronic surgical case.
- All perioperative records, intraoperative records, anesthesia records and standing orders have the patient name, procedure, physician, patient sex and patient age.
2. Improve the effectiveness of communication among caregivers
- Electronic documentation of verbal and telephone orders and any standing orders, including time the verbal was given and when it was read back for clarification. Auto-alerts flag verbal orders that were not “read back” or require electronic signature.
3. Improve the safety of using medications
- Incorporation of standard drug databases permits real-time drug interaction and allergy checking.
4. Reduce the risk of healthcare associated infections
- Electronic documentation of all antimicrobial agents and all other preps used for prophylaxis.
5. Reduce the risk of surgical fires
- Automatic timer to confirm alcohol-based prep has fully dried.
To take just one final example that is in the news, let’s examine sponge counts. A recent study in the Annals of Surgery suggests that one in eight cases had counting discrepancies, with 45 percent of those discrepancies involving counting sponges. EMR features that address this issue include:
- Electronic form fill-in fields to register counts of sponges, needles, instruments and other items.
- Ability for users to add items between counts and have the software keep an up-to-date running count.
- Two staff members can sign off to confirm that both have the same count.
- Circulating nurse documentation to capture course of action in event of a wrong count.
The impact of all of these features on quality and safety is substantial on an individual case basis. Cumulatively, they create a powerful, consistent quality environment. That environment not only satisfies regulatory demands, it also reduces costs of inefficient manual processes, provides strong documentation to lessen liability exposure and builds opportunities to boost revenue by demonstrating evidence of high standards and outcomes.
As the demands for pursuing quality initiatives multiply going forward, technology such as EMR will need to be considered as part of the solution.
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