BWH, MGH Advance Acute Care Documentation Project
Taking another step closer to a fully implemented electronic medical record, more than 300 clinicians came together in May, June and July to develop and standardize the content that makes up current paper flow sheets, assessments and notes including admission, progress, consult and procedure, and to develop tools that will assist in facilitating collaborative interdisciplinary patient care. This work is in support of the implementation of Meta Vision as part of the Acute Care Documentation project (ACD).
“We are extremely fortunate to have commitment for the project by a broad representation of BWH clinicians. They have shown, through the accelerated design sessions, their enthusiasm, attention to detail and willingness to approach this process with an underlying commitment to interdisciplinary collaboration,” said Denise Goldsmith, MS, MPH, RN, manager of Nursing Informatics and project leader for Patient Care Services.
“Thank you for pushing the envelope, for making us rethink how we document currently and for coming to consensus on issues that were not always straight forward,” said Marcy Carty, MD, MPH, director of Clinical Ops Improvement, to the physicians, nurses, social workers, pharmacists, therapists and other care providers who attended the sessions at an offsite conference center with Deloitte Consulting.
Three years in the planning, ACD is a joint effort between BWH and MGH to roll out electronic flow sheets and basic notes to all clinicians. Successfully carrying out a major change process such as this is dependent on the people most affected by the change. Ongoing accelerated design sessions, like the ones held in May, June and July, seek the feedback of users to agree on and standardize content for items that are currently part of existing paper documents on inpatient units in preparation for the transition to electronic documentation.
“For all of us, the primary objective of this work is to improve the quality of care we provide our patients by improving the manner in which we capture our work in the patients health record. The development and implementation of an interdisciplinary electronic inpatient documentation system will be a transformative process for our organization,” said Goldsmith.
Both MGH and BWH will conduct user acceptance test pilots in November 2010.
If you would like to learn more about Acute Care Documentation, contact Denise Goldsmith, Marcy Carty, Jackie Raymond or Allison Benoit.