Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program

Background: Introducing an electronic medical record (EMR) system into a complex health care environment fundamentally changes clinical workflows and documentation processes and, hence, has implications for patient safety. After a multisite "big-bang" EMR implementation across our large public health care organization, a quality improvement program was developed and implemented to monitor clinician adoption, documentation quality, and compliance with workflows to support high-quality patient care.

Objective: Our objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation.

Methods: The Model for Improvement quality improvement framework guided cycles of "Plan, Do, Study, Act." Steps included design, pre- and pilot testing of an audit tool to reflect expected practices for EMR documentation that examined quality and completeness of documentation 1-year post-EMR implementation. Analysis of initial audit results was then performed to (1) provide a baseline to benchmark comparison of ongoing improvement and (2) develop targeted intervention activities to address identified gaps.

Results: Analysis of 1,349 EMR record audits as a baseline for the first cycle of EMR quality improvement revealed five out of nine nursing and midwifery documentation components, and four out of ten medical documentation components' completion and quality were classified as good (>80%). Outputs from this work also included a framework for strategies to improve EMR documentation quality, as well as an EMR data dashboard to monitor compliance.

Conclusion: This work provides the foundation for the development of quality monitoring frameworks to inform both clinician and EMR optimization interventions using audits and feedback. Discipline-specific differences in performance can inform targeted interventions to maximize the effective use of resources and support longitudinal monitoring of EMR documentation and workflows. Future work will include repeat EMR auditing.