Sleep Medicine Structured Clinical Documentation And Implementation Toolkit

Pixabay License | Source: mcmurryjulie , Altered aspect ratio.
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Quality of sleep and disorders thereof have been difficult to quantitate in a comparable manner needed for investigation of effective interventions. Electronic health records (EHR/ EMRs), mobile devices and wearables could remove that barrier. An effective modern EHR should be able to track therapy outcomes & quality of care, efficiently facilitate clinical decisions, and enhance the quality of transition between different medical personnel. Currently patient sleep and neurological factors are rarely uploaded to the EHR routinely.

To meet this challenge Roberta Frigerio of NorthShore University HealthSystem, Chicago, USA, and colleagues, participated in a department-wide project addressing quality improvement and practice based research in neurology by building a structured clinical documentation support (SCDS) and clinical decision support toolkit within their EHR. They describe the development of a sleep toolkit supporting best practices in a publication in the journal Sleep Science and Practice.

The practice of sleep specialists from the Department of Neurology at four hospitals, and at six outpatient sites are now unified by the toolkit. The toolkit’s development implemented:

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  1. A structured clinical documentation support (SCDS) EHR tool 
  2. Enrollment reports
  3. Required descriptive patient data
  4. Data quality assurance
  5. Quality improvement
  6. Clinical decision support (CDS) tools
  7. Tools to share data among medical colleagues in the network

As of May 1, 2019, the department has evaluated 18,105 patients with the purpose built sleep toolkit, including up to 836 fields of data per office visit. Monthly reports are generated including the number of patients with insomnia, sleep related movement disorders, hypersomnias of central origin, parasomnias, circadian rhythm sleep disorders as well as demographics.

Detailed information related to specific symptoms, sleep medication use, and family history of sleep disorders were collected. Several score test measures are recorded that can be evaluated longitudinally. For example, a DNA biobank is being constructed in which the enrollment process is triggered by a CDS that scans the EHR for eligibility criteria. 

“In conclusion, SCDS toolkits, as well as CDS features, may be used to standardize a sleep medicine office visit. Workflows may be optimized to deliver patient care, and progress notes transformed from unstructured text to structured documents with discrete data points, easily captured in the EMR,” stated the authors.