Concept and implementation of a computer-based reminder system to increase completeness in clinical documentation

Abstract

Purpose: Medical documentation is often incomplete. Missing information may impede or bias analysis of study data and can cause delays. In a single source information system, clinical routine documentation and electronic data capture (EDC) systems are connected in the hospital information system (HIS). In this setting, both clinical routine and research would benefit from a higher rate of complete documentation.

Methods: We designed a HIS-based reminder system which identifies not yet finalized forms and sends reminder e-mails to responsible physicians depending on escalation level. The generic concept to create reminder e-mail messages consists in database queries on not-finalized forms and generation of e-mail messages based on this output via the communication server. We compared completeness of electronic HIS forms before and after introduction of the reminder system three months each.

Results: Completeness increased highly significantly (p<0.0001) for each form type (medical history form 93% (145 of 156 forms) vs 100% (206 forms), stress injection protocol 90% (142 of 157 forms) vs 100% (198 forms) and rest injection protocol 31% (45 of 147 forms) vs 100% (208 forms)). Forty-six reminder e-mails to the responsible study physician and 53 reminder e-mails to the principal investigator were sent to finish 2 medical history forms, 8 stress and 20 rest injection protocols. These 2 medical history forms were completed after 1 and 56 days. The median processing time of the stress injection protocols in the post-implementation phase was 18 days (range from 1 to 60 days). The median processing time of the rest injection protocols was 26 days (range from 5 to 37 days).

Conclusion: A computer-based reminder system to identify incomplete documentation forms with a notification and escalation mechanism can improve completeness of finalized forms significantly. It is technically feasible and effective in the clinical setting.