Emergency Department Documentation Enhancinator is an interactive App that:
- Enhances emergency department patient engagement
- Enhances patient care and documentation
- Improves billing and revenue
- Decreases chart audit risk and downgrading level of care

The Problem:
1.) Documentation
Currently caregivers in the emergency department (ED) obtain and document a guided History of Present Illness (HPI) and pertinent Review of Systems (ROS). It is often difficult and time consuming to obtain the most useful information from the patient and those with them, and to accurately and completely document all the desired characteristics of the HPI, as well as an adequately complete ROS.

An ideal HPI, particularly for Chief Complaints such as chest pain and abdominal pain, includes several facets.

• Character • Timing - Onset, duration, continuous/intermittent, prior
• Location • Severity
• Radiation • Associated Symptoms
• Aggravating/Alleviating Factors

Caregivers may not be able to obtain or document this information reliably due to several factors.
• Time constraint of busy ED limits caregiver ability to obtain, recall and transcribe the information
• Numerous questions, phrased different ways, may be required to obtain the information.
• Well intended others present with the patient may wax long and off-the-mark, even answering a simple question.
• Patient may not be able to provide straightforward answers to the questions.
• Patient may provide multiple unusual words well describing their experience of the pain, but caregiver can’t recall patients own words when documentation occurs.
• Caregivers document in great haste.
• Even scribes may lack the knowledge and experience to separate the 7 critical characteristics of Chief Complaint and useful ROS from other non-pertinent information provided during the evaluation.

It is even more problematic to obtain and document The Review of Systems. Billing requirements for certain levels of care require a certain number of components of the ROS be documented (e.g. Level 5 = 10 elements). It is not usually straightforward to ask the appropriate questions for a reasonable ROS and not all components garnered may make it into the documentation! Further, this component of documentation is highly problematic for the coders to extract. Templates stating “10 systems were investigated in the ROS and were negative,” or wording such as “ROS – All systems negative,” are extremely problematic as they are A.) Unlikely to have been truthfully acquired and to be accurate and B.) expose the institution to risk when ED documentation is audited.

Further, it is clear that most emergency departments lose revenue due to downgrading of level of care from inadequate documentation of the ROS. At an ED where one of Wellesley Hills Partners physicians is employed, a recent internal audit was performed to optimize billing. The audit found that 20 of 46 charts with inadequacies that resulted in downgrading occurred due to problems with ROS documentation (see Appendix of associated slide presentation deck).

2.) Patient Engagement
Many forward-thinking institutions are investing significant resources into understanding and enhancing patient engagement. The emergency department faces significant challenges to providing optimal patient care that results in highly satisfied patients and families. This, in turn, could result in meeting expectations for ACO-mandated measures of how well your doctors communicate (ACO metric #2), patients’ rating of doctor (ACO metric #3) and shared decision-making (ACO metric #6), as well as other measures such as Press-Gainey. Busy ED caregivers usually provide care to multiple patients simultaneously under great pressure for time and space, not uncommonly in hallways or after a patient is allegedly admitted. It is difficult to inform and educate patients and loved ones with regard the chosen workup and treatments, and to provide updates. Patient engagement is now a major initiative at some our nation’s most innovative healthcare institutions.

The Solution:
EDDE is designed to create patient engagement with their care in the ED, providing an innovative tool for communication and capturing their voice, facilitating shared medical decision-making and enhancing the relationship of the patient and their loved ones with caregivers, the emergency department and Allegheny Health Network. Please follow the link to the folder with both the pdf description and ppt presentation to see our concept for Allegheny.

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