|Year : 2018 | Volume
| Issue : 1 | Page : 30-32
Revamping the broken electronic medical record in academic dermatology in the United States: An “Epic” endeavor
Molly B Hirt, Maria K Hordinsky, Brittney Schultz, Ronda S Farah
Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
|Date of Web Publication||31-Jan-2018|
Dr. Ronda S Farah
Department of Dermatology, University of Minnesota, 516 Delaware St. SE, MMC 98, Phillips-Wangensteen Building, Suite 4240, Minneapolis, Minnesota
Source of Support: None, Conflict of Interest: None
Many Healthcare institutions face continued challenges related to electronic medical record use (EMR). Within this viewpoint article, we seek to share with our dermatology colleagues our institutional experience on the creation of standardized dermatology records. In our experience, key elements are needed to implement a standardized record, including faculty buy-in, reconciliation with dictation, selection of a leader, and design of the standardized record template. Creation of a standardized record should not only account for the clinic but also patient handouts and support staff templates. We have obtained preliminary evidence that the use of an EMR template not only reduces the cost of dictation but also improves documentation. In addition, we have not seen evidence of over documentation. However, more studies are needed to understanding how a standardized EMR impacts billing, coding, teaching and overall, patient care.
Keywords: Electronic medical record, Epic, medical education, quality improvement
|How to cite this article:|
Hirt MB, Hordinsky MK, Schultz B, Farah RS. Revamping the broken electronic medical record in academic dermatology in the United States: An “Epic” endeavor. J Dermatol Dermatol Surg 2018;22:30-2
|How to cite this URL:|
Hirt MB, Hordinsky MK, Schultz B, Farah RS. Revamping the broken electronic medical record in academic dermatology in the United States: An “Epic” endeavor. J Dermatol Dermatol Surg [serial online] 2018 [cited 2019 Sep 17];22:30-2. Available from: http://www.jddsjournal.org/text.asp?2018/22/1/30/224394
| Introduction|| |
With increasing emphasis on patient satisfaction, health-care entities face an ongoing challenge to remain efficient without compromising patient care. Some consider the electronic medical record (EMR) the 1990s promise to drive these improvements. For many, however, this has been a broken promise that has actually resulted in an increased burden. This has been especially true for complicated systems such as academic institutions, as they are large palettes of physicians, residents, medical students, nurses, scribes, and others utilizing the EMR. In an effort to maximize the “tools” available in our University of Minnesota Department of Dermatology Epic EMR, we launched a 2 years “Epic endeavor”. Herein, we seek to share our EMR development plan, experiences, and ideas with our dermatology colleagues.
| Obtaining Faculty Buy-In|| |
The EMR improvement experience will be different at each institution. The story of EMR growth at our institution began with obtaining faculty buy-in. As within any great idea in an academic setting, convincing all faculties was key. After demonstrating that important information was occasionally missed or deeply buried in the prior and inconsistent documentation, we were able to obtain faculty consensus through the presentation of an Epic development plan where we proposed the use of a uniform EMR template. This universal template was designed and presented after a careful survey of each faculty's individual templates. One unique feature also added at the University of Minnesota was the dermatology problem list, which provides a brief synopsis of the patient's dermatological diagnoses and treatments at the top of the record. The entire department was comfortable with the transition, saw the added value, and liked the flexibility.
| The Electronic Medical Record and Dictation|| |
Of course, the elephant in the room, known as “dictation,” remained. Our goal was not to eliminate dictation as an option but rather to create a standardized note format that could bridge between dictation and computerized notes. Therefore, for the ease of reading and necessary “copy and paste” functions between computerized and dictated notes, a standardized font and text were selected. Faculty also continued to have the option to “bypass” the standardized record format when dictating so as not to lose flexibility from this option when appropriate.
| Selecting a Leader|| |
One faculty member was then honored with the role of “Dermatology Informatics Lead,” Dr. Ronda Farah. This designee functions as the department's “go-to” person for faculty Epic concerns and has the ability to connect rapidly with the department's informatics technical assistant. The focus of our 1st year “Epic endeavor” was the initiation of the standardized template, as this is the cornerstone for improving utilization of Epic. In this year, the Informatics Lead began to understand what was needed to implement a standardized EMR, such as funding, resources, and technical training required to meet this goal. The Informatics Lead attended Epic building classes at the Epic headquarters, also known as the “Milky Way,” in Verona, Wisconsin. Epic offers classes for physicians to learn how to implement tools such as the standardized clinic record, smart phrases, dot phrases, and orders sets. With the goal of the standardized template in mind and training through Epic completed, the Informatics Lead then had the tools to build the template. The department's Epic technical assistant, affiliated with practice plan, was available for questions or concerns.
| Implementation of the Standardized Record|| |
Once the template was created, the hurdle of implementation became apparent. As academic centers have a potpourri of physicians, residents, medical students, and scribes, each of their documentation nuances should be considered. Therefore, we created four versions of the standardized record accounting for these issues. For example, medical students are still learning how to document dermatologic exam descriptions; therefore, this area is left in free text format. Faculty and scribes, on the other hand, are given “menus” for common disease descriptions.
At our institution, we tailored an orientation for each type of documenter, including residents, medical students, and scribes. For residents and medical students, we recorded a 10-min video explaining how to use our standardized record. We also elected a Resident Informatics Lead, Dr. Brittney Schultz, to serve as the residents' “go-to” person for questions regarding Epic and the standardized clinic record. Finally, scribes had to undergo rigorous in-person training with prior scribes or the Informatics Lead. One scribe was designated as a “lead scribe,” and helped with the process of training and orienting new scribes.
| Epic Ideas for Patient Handouts|| |
In addition to standardizing patient templates, we initiated quality improvement projects and reached out to other institutions to develop and create patient handouts to serve as a helpful tool for both patients and physicians. These electronic handouts can be attached to the Epic “after visit summary,” for patients to later reference. However, these documents require continued review, updates and a process to ensure they stay up-to-date.
| Integrating Support Staff|| |
The use of the standardized record was also expanded to other team members such as nurses, medical assistants, and support staff. At our institution, nurses have a standardized record for tasks such as rooming take, medication records, refill requests, safety check-lists, etc., Orientation to Epic is performed by the Informatics Lead alongside other nursing staff. Nursing often finds these computerized patient handouts helpful when fielding questions from patients in clinic or on the phone.
| Future Directions with the “Epic Endeavor”|| |
After standardized documenting templates, patient handouts, and nursing resources fall into place, the work is not complete. There will continue to be requests to edit templates, add or change handouts, or create new items such as orders, smart-sets, photography, consents, and flow sheets. Questions regarding the EMR will frequently arise and need to be addressed. The Informatics Lead is key to problem-solving these issues. The Lead may consider bringing concerns to the entire faculty as the record updates, or there are new additions and changes. Furthermore, the Informatics Lead should become integrated with the institution's informatics team, to represent your own specialty's needs within the EMR.
To examine the effectiveness of the standardized dermatology clinic record at the University of Minnesota, preliminary retrospective and survey studies were performed., From these studies we have not identified excessive over documentation. We have seen decreases in dictation costs for our department and improved documentation. In conclusion, the creation and implementation of standardized clinic records at academic institutions can be daunting, but is an attainable task [Figure 1]. Going from an EMR mess to magnificence may be just a few “clicks” away.
|Figure 1: Flow sheet with steps for the implementation of the standardized record within the electronic medical record at an academic institution|
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Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mello RN, Farah RS. Evaluation of the cost of dictation after implementation of a standardized electronic medical record. In: American Academy of Dermatology 75th
Annual Meeting. Abstract nr 4990. Orlando, FL; 3-7 March, 2017.
Hirt MB, Dodd EM, Lunos S, Farah RS. A chart review investigating the effects of standardized dermatology records on skin exam documentation within an academic institution. In: American Academy of Dermatology 75th
Annual Meeting. Abstract nr 5293. Orlando, FL; 3-7 March, 2017.
Schultz B, Farah RS. Improving clinical documentation in outpatient dermatology clinic introduction of the Dermatology Problem List (DPL) and standardized note templates. In: MMCGME Fifth Annual Quality Forum. Minneapolis, MN; 31 May, 2017.