Optimizing the electronic medical record to improve patient care and conduct quality improvement initiatives in a concussion specialty clinic

ABSTRACT

Objective: To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice-based research in a concussion (mild traumatic brain injury; mTBI) clinic.

Methods: We built a customized structured clinical documentation support (SCDS) toolkit for patients in a concussion specialty clinic. The toolkit collected hundreds of fields of discrete, standardized data. Autoscored and interpreted score tests include the Generalized Anxiety Disorder 7-item scale, Center for Epidemiology Studies Depression scale, Insomnia Severity Index, and Glasgow Coma Scale. Additionally, quantitative score measures are related to immediate memory, concentration, and delayed recall. All of this data collection occurred in a standard appointment length.

Results: To date, we evaluated 619 patients at an initial office visit after an mTBI. We provided a description of our toolkit development process, and a summary of the data electronically captured using the toolkit.

Conclusions: The electronic medical record can be used to effectively structure and standardize care in a concussion clinic. The toolkit supports the delivery of care consistent with Best Practices, provides opportunities for point of care decision support, and writes comprehensive progress notes that can be communicated to other providers.

KEYWORDS:

• Brain concussion
• point-of-care systems
• documentation
• electronic health records
• office visits

Acknowledgments

The authors acknowledge the generous funding support of the Auxiliary of NorthShore University HealthSystem with respect to the initial building of electronic medical record (EMR) toolkits, and thank the medical assistants, nurses, neurologists, EMR Optimization and Enterprise Data Warehouse programmers, administrators, and research personnel at NorthShore University HealthSystem who contributed to the quality improvement and practice-based research initiative using the EMR. The authors thank Hannah Moulthrop, MS, for her assistance with copy-editing, preparing figures, formatting, and submitting the manuscript for publication.

Conflicts of interest

The authors declare no conflicts of interest. This work was supported by a grant from the Agency for Healthcare Research and Quality (R01HS024057) and the Auxiliary of NorthShore University HealthSystem with respect to the initial building of electronic medical record (EMR) toolkits.

Additional information

Funding

This work was supported by the Agency for Healthcare Research and Quality [R01HS024057].