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Keywords:

  • meaningful use;
  • electronic health record;
  • balanced scorecard;
  • clinical documentation;
  • trend analysis

Poster Presentation

  1. Top of page
  2. Poster Presentation

Purpose for the Program

There is no greater current challenge for healthcare organizations than clinical information and documentation. It is through the gathering and strategic use of accessible information about the patient, care provided, and outcomes that we will be able to measure and improve efficacy of care.

Proposed Change

With the evolution and implementation of the electronic health record (EHR) in 2011, Palomar Health launched the process to support the health system documentation, trend analysis, and business practices in both low-risk and high-risk practice settings. The addition of the perinatal EHR documentation component was strategically planned for phase two of the implementation. This phase also included the retiring of a legacy system currently being used for documentation by the obstetrics service line at multiple locations.

Implementation, Outcomes, and Evaluation

This project blends documentation design and validation, continuing education, and ongoing performance improvement to achieve regulatory compliance and goals. The perinatal EHR is intended to provide all members of the healthcare team with comprehensive, accurate, and timely patient information. Staff-led teams completed a design review of data collection, clinical, and registration forms, along with integration to surgical scheduling and documentation. In addition, key standardized reports were identified. These reports support statistical analysis of delivery data as well as department statistics. An aggressive timeline was set with postimplementation benefits identified and measured.

Implications for Nursing Practice

The project work correlates nicely with the establishment of a freestanding Women's Hospital and alignment to standardize practice and policy as well as strengthen relationships within the health system. Staff and leaders from both sites were instrumental in the success of the project. The next phase of this project continues to focus on strategic alignment of policy and practice with the creation of custom reports and advanced data abstraction for benchmarking.