Poster Presentation
Sunday, November 4, 2007
10:30 AM - 11:45 AM
Sunday, November 4, 2007
1:30 PM - 2:45 PM
Using E-Clinical Documentation to Enhance and Facilitate Reporting of Core Measures and Other Regulatory Requirements
Heather Scroggins, RN, BSN and Stephanie Gaworski, RN. Nursing Informatics, John Peter Smith Health Network, Fort Worth, TX, USA
| Learning Objective #1: understand how Health Information Technology (HIT) can facilitate compliance with documentation of core measure. |
| Learning Objective #2: visualize ways agencies can developed electronic documentation tools to enhance compliance. |
JPS Health Network (JPS) is a public teaching health network. We have over 95,000 patient days and 628,000 outpatient visits a year. Both nurses and physicians are challenged every day to manage patients and complete their thorough documentation. Our quality staff was spending hours abstracting data from our paper records. Utilizing technology to enhance compliance is absolutely the answer. Documentation is performed for various reasons including record keeping, communication, and regulatory agencies such as JCAHO, CMS, and local health departments. In addition, hospitals are now reimbursed based on pay for performance. Although clinicians do an excellent job of performing these tasks, we are continually searching for efficient ways to document and report these measures. Our objective is to make documentation of these requirements embedded in the patient care process and seamless or invisible to the clinician. We will discuss the changes made within our facility and how they promote e-documentation as well as reporting required data elements in a more streamlined and efficient manner. In addition, we will give examples of JCAHO and CMS measures entrenched in our Hospital Information System. We will review how we implemented rules to prompt clinicians for our documentation standards. Finally, we will discuss the use of our data repository and its role in enhancing computerized audits and reports.We will share some statistics of pre and post implementation displaying our improved compliance with ORYX core measures and other regulatory agency required documentation.