| Description |
Background: Clinical data is essential for tracking diseases, managing finances, and patient safety (Bowman, 2013). By monitoring clinical data, clinics can achieve outcome tracking and enhanced health outcomes (Tran et al., 2022). This information can be utilized in various ways, including quality improvement projects and grant applications. Enhancing a clinic's capacity to gather clinical data can be achieved through modifications to existing workflows and ICD-10 code applications. Local Problem: A rural free clinic in Utah had difficulty obtaining diagnostic information about patients seen at the clinic. Usually, data captured in a clinic is a by-product of billing using ICD-10 diagnostic codes through an electronic health record (EHR). As a free clinic, however, they do not bill a patient or insurance; correct coding was unnecessary, and codes being entered were often incorrect. A workflow analysis identified the primary cause as a lack of standardization to navigate the billing-related data entry and an inability to determine correct ICD-10 codes. There was also a lack of confidence in using the report sets contained within the electronic reporting system. Methods: An initial clinic assessment was conducted to identify the issues associated with the lack of quality clinical data. Based on this assessment, workflow monitoring, revision, and an appropriate listing of ICD-10 codes were developed. The executive director, project lead, project chair, and nursing staff were key stakeholders in this project. Interventions: Before project implementation, a literature review, retrospective chart review, and clinic workflow monitoring were conducted. A list of the most common ICD-10 codes was created, staff were educated on EHR usage, and initial database reports were obtained. During implementation, weekly chart reviews and PDSA cycles were conducted. Minor Adjustments to workflow were completed throughout the project. A post-implementation chart review, staff interviews, and final database report sets were obtained. Results: Standardized workflows improved data tracking, staff satisfaction, and system usability. Pre- and post-implementation reviews of patient encounter data showed notable improvements. There was a 74.5% increase in the entry of ICD-10 codes into the EHR. The use of the EHR problem list increased by 341%, while the problem summary usage increased by 1,900%. Encounters saved and closed by providers, a necessary part of completing the data capture process, saw more than a 937% increase. Nursing staff reported enhanced satisfaction and greater feasibility in accessing patient data. The project established a lasting framework for ongoing staff training and future data retrieval needs, ensuring long-term usability for the clinic. Conclusions: Implementing standardized EHR workflows and ICD-10 codes improved data tracking and the ability to obtain reliable and reproducible data. There is a high probability of sustainability, as the educational materials and the ICD-10 coding sheets will be available for new employee orientation and training. The ICD-10 coding sheets will continue to be expanded as the clinic grows and offers additional services. |
