title: Real-time checking of electronic anesthesia records for documentation errors and automatically text messaging clinicians improves quality of documentation.
abstract: BACKGROUND
  The quality of electronic anesthesia documentation is important for downstream communication and to demonstrate appropriate diligence to care. Documentation quality will also impact the success of reimbursement contracts that require timely and complete documentation of specific interventions. We implemented a system to improve completeness of clinical documentation and evaluated the results over time.
  
  
  METHODS
  We used custom software to continuously scan for missing clinical documentation during anesthesia. We used patient allergies as a test case, taking advantage of a unique requirement in our system that allergies be manually entered into the electronic record. If no allergy information was entered within 15 min of the "start of anesthesia care" event, a one-time prompt was sent via pager to the person performing the anesthetic. We tabulated the daily fraction of cases missing allergy data for the 6 mo before activating the alert system. We then obtained the same data for the subsequent 9 mo. We tested for systematic performance changes using statistical process control methodologies.
  
  
  RESULTS
  Before initiating the alert system, the fraction of charts without an allergy comment was slightly more than 30%. This decreased to about 8% after initiating the alerts, and was significantly different from baseline within 5 days. Improvement lasted for the duration of the trial. Paging was suspended on nights, weekends, and holidays, yet weekend documentation performance also improved, indicating that weekday reminders had far-reaching effects.
  
  
  CONCLUSIONS
  Electronic anesthesia documentation performance can be rapidly managed and improved by using an automatic process monitoring and alerting system.
authors.affiliation: Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA. wsandberg@partners.org
authors.forename: Warren S
authors.initials: WS
authors.lastname: Sandberg
authors.forename: Elisabeth H
authors.initials: EH
authors.lastname: Sandberg
authors.forename: Andreas R
authors.initials: AR
authors.lastname: Seim
authors.forename: Shaji
authors.initials: S
authors.lastname: Anupama
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Ehrenfeld
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Spring
authors.forename: John L
authors.initials: JL
authors.lastname: Walsh
mesh_terms: D000761:Anesthesia Department, Hospital; D004282:Documentation; D001330:Electronic Data Processing; D006751:Hospital Information Systems; D006801:Humans; D006967:Hypersensitivity; D019451:Information Management; D016347:Medical Records Systems, Computerized; D017010:Reminder Systems; D012984:Software; D013647:Task Performance and Analysis; D013685:Telecommunications; D013997:Time Factors