Blog & Articles

Imagine this scenario: You have been following this 22-year-old primigravida patient since she transferred into your practice at 18 weeks gestation. She tells you that she started her pregnancy weighing 195 pounds; it is now two weeks before her due date and she weighs 248 pounds. 

She failed her 28-week glucose screen; after the 3-hour oral glucose tolerance test, she was diagnosed as being a gestational diabetic. Despite referrals to a dietitian and to the Diabetes Clinic, her blood sugar control and dietary compliance have not been good. At her prenatal visit last week, her fundal height was measured at 43 cm.

Every healthcare professional is familiar with the traditional learning methods of classroom lectures, texts, conferences and hands-on clinical training. For “experienced” older clinicians (like me) educated during the pre-internet era, these were the exclusive methods employed during college, medical/nursing school, internship, residency and beyond. You went to lectures, hit the books, and relied on the “watch one, do one, teach one” process of mastering new procedures.

In a previous article entitled “Should Your EHR Documentation Templates Include Chief Complaint Specific Content,” we emphasized the importance of providing chief compliant-specific content in physician documentation templates for medical specialties that are susceptible to diagnosis-related errors. Let’s advance that concept a step further and explore what other features could be built into an EMR to increase compliance with the key drivers of clinical decision-making in the history and physical exam. For example, would it make a positive impact on patient safety if certain clinical elements in the template were highlighted to draw a greater level of awareness and compliance? For the sake of this discussion, call that “Guidance.” What does that look like? The image below is an example of what Guidance looks like in a new physician documentation application called Medical Professor™. 

Electronic Medical Record (EMR) and Electronic Health Record (EHR) systems were developed to satisfy several important needs (I will use EMR and EHR interchangeably). Just to name a few: legible documentation of patient encounters, satisfaction of coding and billing requirements, regulatory compliance, prevention of medication errors, clinical pathway utilization, medical-legal defensibility, and data compilation. Having seen and used several EMR systems, I can tell you that they were not developed with the primary goal of improving user efficiency.

As a follow-up to last week’s article The History of EMRs: Opportunities to Improve Patient Safety, we explore the philosophy around providing EHR documentation templates that include specialty-specific, chief complaint clinical content. Doing so provokes a few big-picture questions about healthcare information technology and the appropriate strategy for designing clinical applications that providers work with daily.

One of our goals at The Sullivan Group is to bring you practical pearls to reduce risk, improve patient safety, and enhance quality in your everyday practice. To that end I thought I would share with you this “alphabet soup” of healthcare risk management and patient safety tips assembled from years of observation and experience.

Over the next eight weeks, we will be providing information on EHRs/EMRs that have proven to improve patient safety, reduce medical errors and reduce litigation. In this first week, we provide historical context on the events leading up to today’s current state of electronic provider documentation. This series aims to help shed light on the improvements available for EMR physician documentation and to provide key takeaways to implement into your providers’ workflow.

With preeclampsia affecting 10% of all pregnancies and rates rising by 25% in the past two decades, it is important to test your knowledge and ensure that all your patients have a strong understanding of the dangers of preeclampsia. This is part II of a two-part series. Part I focused on definitions, risks, prevention and diagnosis of preeclampsia; part II focuses on HELLP syndrome, treatment, eclampsia, future risk and resources.

Our mission at The Sullivan Group is to positively change clinical practice, improve patient safety and reduce malpractice litigation. Because of this, we are often asked by clinical leaders and clients to explore the impact our RSQ® Solutions platform may have on other areas of the healthcare business. A Chief Nursing Officer with whom we have worked for the past several years connected with me at the 19^th Annual NPSF Patient Safety Congress in Orlando, FL, with a similar inquiry. She asked if we had any evidence to support a relationship between our work with improving nursing competency/patient safety and nursing retention rates. 

The case presentation will be a little different than our typical failure to diagnose an aortic disaster or other common “failure to diagnose” entity in emergency medicine. Although those are great teaching cases, there is another critically important side to the patient safety coin. It is critical to do the appropriate testing to identify potentially fatal presentations, but it is equally important to understand when such testing is inappropriate − testing that itself may by unnecessary and may actually cause morbidity.