Kenneth Seerup Jørgensen
Area Manager for the Facility and ICT Strategic Department, Lillebælt Hospital
Lillebælt Hospital improves the efficiency of journal audits with text analysis
The orthopaedic surgery department has done away with resource-intensive manual journal reviews, replacing them with an IT solution that performs quality assurance for the entries in all patient journals.
In the past, just 1% of all journals at Vejle Hospital’s orthopaedic surgery department underwent spot checks four times annually as part of journal audits performed by a doctor and a secretary. These 160 journals reviewed four times annually provided only limited learning to those who committed the errors – and above all, the review was very time-consuming.
“We found errors in 33% of the journals we reviewed in spot checks. These involved incorrect entries or inadequate diagnoses or treatments. For example, if a patient with a thigh bone fracture developed pneumonia during the hospitalization, the pneumonia and its treatment were all too often not registered,” says Senior Chief Physician Sten Larsen.
“If the project meets our expectations, it can immediately be deployed to other orthopaedic surgery departments throughout the Lillebælt Hospital Group – and with a few adjustments in codes and terminology, to other surgical departments that are already using electronic patient journals.”
Kenneth Seerup Jørgensen
Automated journal audits
As part of the project “Clinically Correct and Timely Registration”, the department has now implemented a system that automatically and thoroughly analyses the journals of all admitted patients. The system utilizes a solution from SAS Institute, which is based on text analysis. The software analyses the doctor’s journal dictations and automatically registers the code associated with the diagnosis and treatment. The new system required extensive adaptation to ensure that both Danish and Latin terms, abbreviations, etc. are correctly interpreted.
“We have been adjusting and testing the system on a running basis. Now we are ready to go the distance with a large volume of journals,” says Sten Larsen, who devised the project in cooperation with Kenneth Seerup Jørgensen, Area Manager for the Facility and ICT Strategic Department. They both participated throughout the development process.
Sten Larsen and Kenneth Seerup Jørgensen expect to conduct a final assessment of the project at the orthopaedic surgery department during the autumn of 2010. The assessment will reveal whether the project has met expectations regarding increased identification of errors and reduced time consumption on staff, thereby giving doctors more time with patients.
“If the project meets our expectations, it can immediately be deployed to other orthopaedic surgery departments throughout the Lillebælt Hospital Group – and with a few adjustments in codes and terminology, to other surgical departments that are already using electronic patient journals,” says Kenneth Seerup Jørgensen.
Information basis for additional improvements
The management of Lillebælt Hospital launched this project to build a data foundation that can also be used for improvements in other areas. For example, the project can help to improve the quality of clinical work, as procedures and diagnoses described in the electronic patient journals are made available in other systems, and thus can provide a better basis for research and further diagnosis.
“Errors may be big or small, significant or insignificant. But it is important to remember that all health policy decisions are based on the statistics compiled using the entries of every clinic. If the figures are incorrect, the basis for making decisions is also incorrect. Therefore, the importance of the Clinically Correct and Timely Registration project extends beyond just our department or hospital,” says Sten Larsen
Contact Morten Krogh Danielsen from SAS Institute if you have any questions about the solution or if you would like to schedule a meeting.
Direct tel.: +45 70 28 26 48.
Manual journal audits was a resource-demanding process that only ensured the identification of errors and deficiencies in 1% of the journals.
The SAS solution utilizes text mining to review all journals and identify inadequate entries, which can then be corrected.
Doctors gain more time with patients – time previously spent on manual audits. All journals undergo quality assurance and staff can better learn from their mistakes.