Template Design and Analysis: Integrating Informatics Solutions to Improve Clinical Documentation.

ABSTRACT

BACKGROUND: Electronic health record templates have served a variety of functions, such as improving documentation for reliable reporting of health care outcomes. Standardizing template documentation has been important for accurately capturing case workload and supporting quality improvement initiatives. METHODS: North Florida/South Georgia Veterans Health System consists of 2 Florida-based hospitals Malcom Randall Veterans Affairs Medical Center (MRVAMC) in Gainesville, and Lake City Veterans Affairs Medical Center (LCVAMC). In the first quarter of fiscal year 2017, MRVAMC and LCVAMC had a below-average case severity index (CSI) of 0.76 and 0.81, respectively, compared with that of the 0.96 national average for the Veterans Health Administration (VHA). An innovative history and physical template design with embedded informatics tools was created to improve clinical documentation. RESULTS: Compliance with standardized history and physical medicine template use was monitored for about 1 year after standardized template implementation. Compliance improved from 43.2% in June 2018 to 89.9% in June 2019 at MRVAMC and increased from 48.2% in June 2018 to 96.9% in June 2019 at LCVAMC. CSI improved to 0.97 at MRVAMC and 1.07 at LCVAMC in the first quarter of fiscal year 2019, which exceeded the VHA national average of 0.89 during the same period. CONCLUSIONS: NF/SGVHS integrated informatics solutions within template design was associated with an increase in CSI via improved clinical documentation.