Designing E-Documentation for a Hybrid, Regional Environment
This is a follow on to my previous post on forms. I am working with a group now to design some clinical documentation and the information captured will be used in several very different environments. These locations are “hybrid” in that some information is electronic and other information is still on paper. A further wrinkle is that the evolution from paper to digital is not going to happen across the entire organization at the same rate, so we need to design a solution that will support various modalities as patients move in their journey.
Right now, the current practice for pre-admission work for elective surgeries is: store electronic results and transcribed documents electronically in a regional system that is accessible in multiple environments. The paper workflow is a little different. There is one paper chart – designed for inpatient care – and it is moved (or bits of it are moved) around to the various locations where a patient will be assessed over the up to 8 months prior to entering the hospital and the collect it all, make sure it is in the right order, and send it to the hospital just before the patient is scheduled to be admitted.
Many challenges here, not the least of which is the workflow associated with completing forms that are not designed for you to do your assessment, but are designed to support inpatient workflows pre and post operatively.
What we are looking at now is how to support two very different workflows in a manner that allows for standardization and flexibility at the same time. Flexibility in the sense that each workflow needs to be supported. Standardization in that the data needs to be captured in a way that allows logical reuse throughout the care process. With the wrinkle that some of that reuse will have to be that the data captured electronically needs to be able to recreate the inpatient PAPER chart through a report writer as the inpatient world will not be changing to electronic documentation at the same time as our pilot sites in the outpatient world.
Interesting times! I will post more on our approaches as we move forward.
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