Dr Maria Schwarz1,2, Prof Elizabeth Ward1,2, Mr Joshua Simmons3, Ms Kristy Perkins4, Mr Philip Juffs5, Ms Sara Burrett6
1Centre For Functioning and Health Research, Brisbane, Australia, 2School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Aus, 3Digital Health Informatics, Metro South Hospital and Health Service, Brisbane, Australia, 4Allied Health, Logan-Beaudesert Health Service, Metro South Hospital and Health Service, Logan, Australia, 5Allied Health, West Moreton Hospital and Health Service, Ipswich, Australia, 6Allied Health and Rehabilitation Sciences, Gold Coast Hospital and Health Service, Gold Coast, Australia
Biography:
Ms Perkins is a physiotherapist and Allied Health leader with experience in the development of the AHNBPDS and digital architecture utilised by Queensland Health Clinicians. She is a member of the QH Allied Health Digital Specialty Group, MSH AH Digital Committee and is currently completing the Digital Health Leadership Australia Digital Health for Managers course.
Abstract:
Background (topic nature, scope and issue under consideration):
Consistency and standardisation of clinical documentation within the Electronic Medical Record (EMR) have been identified as important mechanisms for improved data access and utilisation. Utilisation of standardised data may promote (i) greater reliability, (ii) data driven workforce and system planning, (iii) improved patient outcomes and (iv) research and quality improvement opportunities.
Purpose:
To maximise capabilities for secondary EMR data utilisation, a thorough understanding of the current state of consistency and standardisation in documentation is required. The aims of the project are to gain a detailed understanding of the current state of clinical workflows and stakeholder perceptions regarding documentation of clinical data elements, including outcome measures and service statistics within the EMR. Subsequently ‘optimisation’ opportunities will be identified, implemented and evaluated.
Method:
The research consists of three components (1) process mapping current workflows, (2) qualitative analysis of manager perceptions, and (3) a “Plan, Do, Study, Act” (PDSA) process to introduce and then evaluate clinician-consumer co-designed digital improvement strategy/s within the current EMR.
Proposed outcomes and conclusions:
It is hypothesised that current documentation practices lack consistency and standardisation (with regards to data entry location, content, and consistency) both within and across sites and Allied Health professions. Further it is expected that managers will identify a number of opportunities for secondary data utilisation (e.g. quality improvement and research related to clinical practice, models of care and workforce) which could be achieved with greater consistency and standardisation of data entry practices in the EMR.