Acute Care Documentation Project Reaches Milestone

Denise Goldsmith, RN, left, and Marcy Carty, MD.

During September’s Acute Care Documentation retreat in Waltham, more than 200 BWH and MGH clinicians saw firsthand the work completed up to this point on Acute Care Documentation system, an electronic platform that enables multiple caregivers to access an inpatient’s record, including flowsheets, assessments and notes, both on site and remotely.

About 250 clinicians from both hospitals committed many hours this spring and summer to develop the core data, functionality and look and feel of the shared inpatient electronic medical records system that will transition the two hospitals from paper to electronic documentation systems. During the September retreat, clinicians and hospital leadership had a chance to preview the system’s layout and content and offer input.

“The ultimate goal of the retreat was to share the work completed to date across all involved disciplines and receive real-time feedback as to how the designs work within a real clinical scenario with multiple users documenting on the same patient,” said Marcy Carty, MD, MPH, director of Clinical Operations Improvement. “To achieve these goals, a multidisciplinary team of clinicians used the system while a multi-disciplinary audience watched and gave feedback based on their clinical workflow and practice. It was very powerful.”

With the implementation of the ACD project, many caregivers will be able to access an inpatient record both onsite and remotely via computers. Handwritten notes will be replaced by typed notes available in MetaVision, the clinical documentation software used for Acute Care Documentation, and coded data fields will feed other databases and reporting tools. In many cases, data from one area will be able to be imported for use in other areas to avoid repeated entries.

Participants had the opportunity to see how MetaVision integrates the clinical workflow and pulls data from other systems within the electronic health record.

Acute Care Documentation is slated to be piloted at both hospitals at the end of 2010.

For more information regarding the Acute Care Documentation Project at BWH, please contact Marcy Carty, Denise Goldsmith or Jackie Raymond.