The Value of New Fields in the Medical Record for Quality Improvement

ABSTRACT Introduction Quality in healthcare delivery is important for the safety and experience of patients with cancer. Effective documentation is an integral component of quality improvment, and accurate documentation can be affected by prompts in the medical record, potentially improving quality of services. Methods The Contemporary Oncology Team (COT) is a Greek private oncology practice that participated in the American Society of Clinical Oncology's (ASCO's) Quality in Oncology Practice Initiative (QOPI). Between 2014 and 2019, COT implemented changes in its paper patient medical record, in order to improve quality of care and documentation. Fields regarding pain, emotional well-being and psychosocial assessment, discussions with the patient and consent about treatment and disease, medication details and cumulative dose, treatment goals, side-effect grading, pregnancy screening, treatment adherence and anticipated duration were added. In this report, we present the association of these improvements with COT performance in QOPI. Results Pain and emotional well-being assessment and documentation were significantly improved by the development of a structured patient follow-up form. In contrast, the assessment of fertility issues, tobacco use, and the documentation of treatment plan and intent did not present a drastic change, because COT performance was already above QOPI average. Conclusion A thorough reform of COT paper medical record according to QOPI standards improved QOPI scores, but more importantly effected a shift in the team's culture to safer and more standardized quality based care.

Healthcare and the Electronic Health Record

The cornerstone of clinical informatics is the Electronic Health Record. This is more than an electronic version of the paper medical record. The use of the electronic record is for more than point-of-care healthcare but rather includes analytics, gap analysis, decision support, and related purposes that would be almost impossible in a paper world. The electronic health record is the present preferred term for the digital systems that coordinate healthcare information. The term electronic medical record was used more prominently in the past. The chapter looks at the transition in this terminology and examines the future move to the personal health record. A case scenario is presented regarding use of the electronic health record system. The future of the system is examined.

Who Watches the Watchers

SummaryThe rise in the use of electronic health records (EHRs) and associated resources over the last decade is leading to the end of the paper medical record and all the risks associated with the use of a paper chart. However, there has not been a concomitant creation of a systematic oversight body that is specifically charged with ensuring the public’s safety through the use of EHR knowledge resource tools or EHRs themselves. We recommend the formation a Health Information Technology Safety Center. Such a center could collect error reports, review EHRs and the knowledge resources incorporated within them, and investigate particularly challenging EHR-related safety issues at participating health care delivery organizations. Safety issues could be identified, corrected, and the solutions widely disseminated.Citation: Labkoff SE, Sittig DF. Who watches the watchers: working towards safety for EHR knowledge resources. Appl Clin Inform 2017; 8: 680–685 https://doi.org/10.4338/ACI-2017-02-IE-0032

Functional Office Design: A Medical Record Department Perspective

The term ‘ergonomics' embodies the relationship of people to their total work environment. In this paper, medical record administrators are encouraged to explore the potential of ergonomics in its widest sense and, when evaluating the design of medical record departments, to keep in mind that office design is fundamental to productivity and staff morale. Medical record adminstrators need to press for changes in office design which not only improve the morale and performance of employees but also enhance the image of the medical record department as a vital and integral part of patient services.