Medical records get a lot of buzz these days. In the past several years the United States Department of Health and Human Services has heavily incentivized private providers to convert paper medical records to electronic systems. Providers in the developing world are tempted with promises of record-keeping magic bullets in the form of handheld tablets, mobile phones, and tele-medicine. But the reality is that you can’t build good electronic records without knowing how to build good paper records in the first place. And most medical records are badly designed. Rarely do we talk about what makes a solid, useful medical record.
How do you thoroughly collect patient medical information while facilitating efficiency during the consultation? How do you empower low-income patients with their own files while retaining copies for yourself? How do you provide guidance to clinicians without making forms unwieldy? We spent the last few months at Jacaranda asking ourselves these precise questions as we redesigned our medical records.
We custom designed our medical records when we launched our first maternity hospital in August 2012. At the time we adapted record templates from academic medical centers and the Kenyan Ministry of Health, but a year of observations taught us that we needed something better designed to guide our clinicians and meet the specific needs of our low-income clients. A few examples:
- Kenyan women often seek maternity care at multiple health facilities, so to ensure continuity of medical information we were in the habit of sending medical records home with patients (like most hospitals in Africa). But this meant that we were left with no in-house client record.
- Poorly designed aspects of our forms had resulted in poor documentation – certain “Bermuda triangle” areas of forms were consistently left unfilled.
- Lack of clarity in the flow of forms had resulted in precious time wasted during triage. We realized we could design the forms to better facilitate efficiency.
How did we redesign?
Our process in a nutshell was: Audit Charts -> Brainstorm with Clinicians -> Revise Forms -> Roll-out Redesigned Documentation.
We began the review process by brainstorming with Jacaranda clinical staff. We conduct weekly medical records audits so we took this opportunity to examine each form line-by-line with our nurse-midwives to determine which sections were most useful and which needed modification or clarification. Meanwhile, we audited historical records to identify which parts of the forms were frequently left unfilled. For example, we concluded that there were opportunities to use the medical record as a cue in medication administration.
Next, we began to revise.
We utilized the lean management methodology of “value stream mapping” to identify each distinct clinical touch point and ranked them by efficiency, risk reduction, and safety. We designed all forms to more explicitly guide the flow of each consultation; for example, to address the pain medication issue, we embedded prompts and charts to remind clinicians of the appropriate dosage.
Additionally, we developed an abbreviated medical record for each client to take home that includes medical notes and tips on healthy pregnancy, while keeping a more detailed version in-house. We created Jacaranda loyalty cards that capture each client’s next scheduled visit as a physical reminder to attend the recommended four antenatal care visits.
Next came the roll-out.
We circulated draft versions of the new medical records to ensure ease of use and quality of content. With team consensus, we tested final versions and facilitated one-on-one training with the entire clinical staff. Today, our nurses are using the revised set of medical records as we simultaneously enter the data into an electronic system for analysis and oversight.
What did we learn?
A few takeaways from the medical record redesign process:
- Medical records help improve quality of care: forms are a great place to incorporate clinician decision-making tools.
- The user interface design is key: clarity of a form makes a big difference in how well clinicians document their casework. The medical record design process can be a good way of understanding core components of clinical operations, like patient flow and clinicians’ behavior.
- Documentation audits are absolutely necessary for safety. Just because you have a medical record in your facility doesn’t mean clinicians are filling it out properly or completely. As one clinical reviewer often says to our nurse midwifes: “You may have done the right medical check but if it’s not documented, it’s not done.”
- The medical record templates that are available off the shelf (for example, from multilateral organizations like WHO or even Ministries of Health) aren’t necessarily inherently well designed for every context. Look inward as you look out.
- Revising records is time-consuming and sometimes frustrating, but engaging clinicians in the design process is a powerful way to get buy-in for change and the best output.
We uncovered many more insights through this process – look out for more on medical records, and the lessons we learned, in the future.