Helping clinicians help themselves: How this health system made entering clinical notes as easy and efficient as possible.

This health system made entering clinical notes easy and efficient

Learn how Huron Perth Healthcare Alliance (HPHA) and Alexandra Marine and General Hospital (AMGH) ditched paper and other outdated transcription methods once and for all with mobile documentation tools — achieving a more efficient and seamless way for clinicians to enter their notes.

Customer Snapshot: Huron Perth Healthcare Alliance

  • Regional health system and hospital serving 135,000 people in southwestern Ontario
  • Huron Perth Healthcare Alliance (HPHA) and Alexandra Marine and General Hospital (AMGH) includes 5 hospitals on a common MEDITECH® EHR system with a combined total of 250 beds and 150 physicians
  • Deployed Commure Care (formerly PatientKeeper) mobile app’s clinical documentation module to allow physicians to easily enter clinical notes from anywhere at any time

Objectives

With a cumbersome EHR experience, the process for providers to enter their clinical notes was an increasingly inefficient and unsustainable challenge for HPHA and AMGH. They needed a new solution to extend the value of their MEDITECH EHR and modernize their clinical documentation technology.

“Some providers were writing their daily progress notes on paper,” said Annette Stelmachuk, RN, a clinical IT analyst at HPHA. “For things like history, physicals, discharges, operative reports, and consults, many would pick up the phone and dictate their notes into a dictation software, and then a transcriptionist would type it for them.”

With a middle person transporting information between providers and clinical notes, clinicians had a habit of leaving incomplete notes in MEDITECH. According to Annette, “They were always left in a draft status. If there were errors or blanks and no one had reviewed them, that’s how they stayed. It was not ideal at all.”

Leaders at HPHA and AMGH knew the providers needed a more efficient and sustainable way for entering clinical notes from patient visits, especially as the typist talent pool dwindled and their transcription software was reaching its end of life.

At a strategic juncture, HPHA and AMGH needed a solution that would sit on top of its MEDITECH EHR so that physicians had an intuitive and customizable solution with a mobile-friendly option to efficiently enter and edit their own notes.

Actions

When leadership began to evaluate options, they turned to Dr. Robert Davis, a tenured physician at HPHA now serving as an IT liaison responsible for evaluating physician-facing software. “It was obvious to me,” said Dr. Davis, “that [Commure Care] was by far the most user-friendly option from a physician perspective.”

HPHA and AMGH had already deployed Commure Care’s clinical results viewing module to physicians several years prior, so extending into clinical documentation with mobile-friendly note templates became the obvious choice.

Empowering physicians with choice

With Commure Care’s ability to easily integrate with front-end dictation tools, HPHA and AMGH decided to give physicians the choice to enter their notes in a way that worked best for them — whether by voice or typing.

Now physicians can type or enter their notes by speaking into their phone using the Commure Care app. It’s especially important for the front-end, speech-to-text dictation system to learn and correct its mistakes to avoid learning bad habits. Fortunately, HPHA and AMGH had the support of their leadership throughout the change management process to help ease physicians into a routine of reviewing and correcting their notes.

Empowering physicians with easy-to-use, customizable tools

Because Commure Care is easily customizable, HPHA and AMGH was able to listen to physician feedback and quickly tailor note templates to meet their needs — a huge selling point for the providers, according to Annette.

While we started with five generic templates, now we probably have 50 templates customized to various specialties and workflows,” said Annette. “Some have tabs and boxes and sections, but we also have what we call speech-friendly ones, which are open text boxes for those who just want to speak into it. We’ve given multiple ways for physicians to do their notes so that they can decide what works best with their workflow.”

Outcomes

Faster access to patient data to inform care decisions

According to Dr. Davis, the tool is not only user-friendly — its mobility makes it a significant time-saver.

“As a physician, you never know when you’re going to get a page or a call about a patient. Rather than run to a computer to look up that patient’s record, you can simply look on your mobile device and the patient’s information is right there. It’s much more efficient, and I think it adds to patient care. I know for a fact that physicians will log into [Commure Care] from home before they come to work, so they already have a head start when they get to the floor of the hospital.”

Streamlined clinical collaboration and decision-making when it matters most

Now, HPHA and AMGH have real-time access to clinical notes, which has made collaboration and decision-making much more efficient. What once took days is now there for automatic viewing.

“In the past with our dictation and transcription workflow, it could take two or three days for a history to be on a patient’s chart, or for a discharge to be on the chart,” according to Dr. Davis. “Now when our providers do a note, it’s there automatically for viewing, and at the same time we send it out electronically. As soon as it’s signed, it’s sent out to family physicians and anyone else that they have copied it to. That wasn’t a possibility before.”

With Commure Care’s provider-friendly mobility and customizability, HPHA and AMGH left the world of paper and transcription behind — drastically improving the clinician and patient experience alike.