Using an Automated Outcomes Solution to Enhance EMR Documentation and Meaningful Use Compliance

Purpose:
Due to lack of consistent documentation and upcoming regulatory requirements related to Meaningful Use, a commitment was made by our organization to implement an automated outcomes solution software. The goal was to improve documentation, enhance quality outcomes, and gain financial benefits.

Significance:
With hospitals facing increased regulatory pressures, quality of care and financial sustainability are key drivers to success. In order to be sustainable, creative methods needed to be developed in order to stay one step ahead of the upcoming regulations.

Strategy and Implementation:
An automated outcomes solution was purchased to allow for the extraction of data from the electronic medical record. Specific reports were developed and shared with key nursing personnel. The reports created were for patients currently in the hospital. The reports included documented patient Braden Scores, advance directive compliance, drug allergies and others. Creating efficiencies in documentation was of utmost importance--not only from a financial perspective, but also from a nursing satisfaction perspective as it relates to tasks. The use of this software has allowed our organization to improve patient safety, quality of care and create efficiencies in nursing documentation.

Evaluation:
The implementation has been a great success as evidenced by increased compliance for one just component of Meaningful Use. The hospital has seen compliance increase from 62% in February 2011 to 90% in May 2011.

Implications for Practice:
The use of an automated outcomes system to extract data has resulted in identifying areas of weakness in nursing documentation which has helped educate nursing staff and streamline documentation where it is most beneficial for improved patient outcomes.