Design and Implementation of Structured Clinical Documentation Support Tools for Treating Stroke Patients

• Published in: Journal of stroke and cerebrovascular diseases Vol. 28; no. 5; pp. 1229 - 1235
• Main Authors: Simon, Kelly Claire, Munson, Richard, Ong, Archie, Gil, Fulvio R., Campanella, Franco, Hillman, Laura, Lai, Rebekah, Chesis, Richard, Tideman, Samuel, Vazquez, Rosa Maria, Meyers, Steven, Frigerio, Roberta, Maraganore, Demetrius
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.05.2019
• Subjects: data collection; electronic health records; neurology; Quality improvement; research design; stroke; Quality improvement; electronic health records; research design; data collection; stroke; neurology
• ISSN: 1052-3057; 1532-8511
• DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.011

Background and Purpose: Standardized electronic medical record tools provide an opportunity to efficiently provide care that conforms to Best Practices and supports quality improvement and practice-based research initiatives. Methods: We describe the development of a customized structured clinical documentation “toolkit” that standardizes patient data collection to conform to Best Practices for treating patients with stroke. The toolkit collects patients’ demographic information, relevant score test measures, and captures information on disability, treatment, and outcomes. Results: We describe here our creation and implementation of the toolkits and provide example screenshots. As of August 1, 2018, we have evaluated 2332 patients at an initial visit for a possible stroke. We provide basic descriptive data gathered from the use of the toolkits, demonstrating their utility in collecting patient data in a manner that supports both quality clinical care and research initiatives. Conclusions: We have developed an EMR toolkit to support Best Practices in the care of patients with stroke. We discuss quality improvement projects and current research initiatives using the toolkit. This toolkit is being shared with other Departments of Neurology as part of the Neurology Practice-Based Research Network.