CIO Stories, III Methodist Healthcare System, San Antonio: Redesign of Clinical Documentation

  • Jennifer Allan Browne
Part of the Health Informatics Series book series (HI)

Abstract

In 1994 the Meditech1 hospital information system was installed in four hospitals within the Methodist Healthcare System (MHS) in San Antonio, Texas. Most modules, such as Lab, Radiology, Pharmacy, and Order Entry, stabilized rapidly and well. The Clinical Documentation module, however, stalled with design problems. Two years after installation, unresolved clinical issues remained:
  • Documentation time had increased.

  • Complex care plans did not effectively communicate patient problems.

  • Excessive interventions were needed to support daily documentation.

  • The patient care plan did not connect with the daily documentation record.

  • Accuracy of the medical record decreased.

  • Fragmented data were produced.

  • Medical records accumulated duplicate and conflicting information.

  • Extracting concurrent and retrospective data proved difficult.

  • Physician dissatisfaction with nursing and the medical record had increased.

Keywords

Advance Directive Nutritional Risk Clinical Documentation Respiratory Therapy Documentation Time 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Allan J, Englebright J. Organizing clinical information systems to manage and improve care. Proceedings of the 2000 Annual HIMSS Conference and Exhibition; 2000 April 9–13; Dallas, TX. Session 80. p. 269–284 [CD].Google Scholar
  2. 2.
    Allan J, Englebright J. Patient-centered documentation. J Nursing Admin 2000; 30 (2): 90–95.CrossRefGoogle Scholar
  3. 3.
    Comerio A. Partner, Adams, Comerio, and Vowell Law Firm. San Antonio, TX.Google Scholar
  4. 4.
    Information, courtesy of Michael G. Freiling, Director of Pulmonary Services, Methodist Specialty and Transplant Hospital, Southwest Texas Methodist Hospital and Methodist Children’s Hospital of South Texas.Google Scholar

Copyright information

© Springer Science+Business Media New York 2004

Authors and Affiliations

  • Jennifer Allan Browne
    • 1
  1. 1.Methodist Healthcare SystemSan AntonioUSA

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