Introduction Healthcare providers are increasingly making the transition from paper to electronic note keeping. This change can be challenging, time consuming and requires full team cooperation. Electronic documents improve accuracy of information recorded, accessibility of data and facilitate future audit and service improvement. Forming an integral part of the IBD standards, the use of information technology and audit are key to ensure patients receive consistent high quality care.
Method A QI Project led by a Core Medical Trainee in Gastroenterology working with a Consultant Gastroenterologist and IBD Specialist Nurse. The SMART aim was ‘80% of IBD clinic encounters will be documented electronically within 9 months’. To achieve this a standardised proforma was developed and refined over several cycles. Proforma fields included information outlined in trust and GMC guidelines for note keeping, plus desirable information for the IBD registry and quality of life questions. The proforma was subsequently embedded into the IT system and rolled out for use by the wider IBD team.
Results In the primary stages electronic notes were scarcely used, limited by user access to IT, time burden and acceptance by IBD team members. Following adaptations the run chart data showed that overall use of electronic notes improved from 30% to 66%. Consultant use increased from zero to 95%. IT complications and case complexity were the biggest contributors of failure to use electronic notes.
Conclusion QI methodology is an efficient way to improve the use of electronic notes using a standardised proforma during IBD clinics. Creation of a user-friendly proforma which is accessible and time efficient are key to implementing change in practice. The use of standardised data ensures consistency of information recording and provides a valuable tool for future audit. Once electronic notes are fully immersed in the IBD service, data can be more easily transferred to the IBD registry and contribute to national statistics to improve patient care.
- Electronic note keeping
- Quality Improvement