Clinical Templates for Electronic Medical Documentation
Synoptic reporting is a template-based method for producing electronic medical documentation that is more timely, more accurate and more actionable than narrative or dictated medical reports. For pathologists, the gold standard are the CAP Cancer Protocols, which can be quickly integrated into EMRs like the Synoptec™ synoptic reporting software. And for radiologists, the RSNA templates can be a valuable starting point for reviewing evidence-based best practices in diagnostic imaging reporting.
But for many clinicians implementing synoptic reporting will require your team to design clinical templates that best suit your patients’ care pathways. How do you develop unique clinical templates to support evidence-based care?
How Do You Develop Synoptic Templates?
A recent Cancer Care Ontario white paper on synoptic radiology reporting outlines the steps their jurisdiction is taking to improve electronic medical documentation for diagnostic imaging in cancer surveillance and care. This includes working groups to develop clinical templates.
Cancer Care Ontario sets several goals for their working groups that overlap with the lessons Softworks Group has learned from our 20 years of developing synoptic templates, with our clinical partners such as Cancer Surgery Alberta, and the University of Calgary’s Dr. Alain Tremblay.
We’d like to share with you some of our best practices for developing clinical templates.
Set up a multidisciplinary design group
When you first think about who should develop a template, the most common answer is the person who does the reporting today—e.g. the surgeon, radiologist, pathologist, etc. These subject matter experts are crucial designers, but in our experience at Softworks Group, we find report readers are often under-represented in the template design process. Clinicians like intake nurses or family physicians may be the primary users of certain medical reports, and clinical templates should be designed with these readers in mind.
A best practice is to assemble a design group that represents the diversity of expertise in the care team, focusing on how medical reports support clinical decision making.
Collect data that supports clinical decision making
When a client first sees Synoptec™, they have a tendency to be a bit too enthusiastic about the amount of data they plan to collect with their synoptic templates. But the biggest template is not necessarily the best template.
Clinical templates should ensure that clinicians can complete reports quickly—in the same or less time than they currently spend with narrative reporting. If reporting becomes a burden due to the volume of data clinicians are being asked to collect, great software quality and having the app available on their smartphone won’t save the program. Particularly in the early stages of synoptic reporting, keep templates as short as possible.
How do you decide which data to collect?
For each element you add to the template, ask your multidisciplinary design team if the element impacts clinical decision making. Ask for examples, get specific, and make sure all care team members weigh in. Ask if the element is necessary to support organization policy or lowers risks such as medical malpractice liability.
Avoid including data that “has always been there” in the narrative report but is no longer useful for clinicians. Also avoid the temptation to collect data that might be useful in future research when no specific research questions have been formulated. A well designed clinical template software enables you to add these questions once they become relevant—without disrupting reporting workflows.
Follow the care pathway with multiple clinical templates
Many care teams are tempted to design the one-template-to-report-everything. But typical care pathways involve multiple visits and different sets of information: assessments, diagnostic tests, procedures, medical outcome measurement, follow-up care, etc. Trying to capture all of these interactions in a single report can create significant reporting delays, hindering care team communication.
A best practice is to create multiple, smaller templates that focus on specific points of care.
One of the most helpful tools to have for the template design process are care pathway diagrams. These can be as simple as sketching out on a whiteboard to help visualize which reports will influence which next-step decisions.
The following image is one of a series of EMR workflow diagrams that Softworks Group created as part of a feasibility assessment for Synoptec™ implementation at the Institute for Reconstructive Sciences in Medicine:
In the workflow diagram above, we used colour coding to indicate when reports will be filled out (yellow), when data needs to interoperate with different systems (grey), and when new procedures will be initiated (orange). This helps template designers understand how individual reporting points support patient care pathways.
How do you know if you have the right reporting points?
When a clinical template can be completed by one individual, at or near the point of care, for a procedure or encounter performed that day. This is a strong indicator that you have the right scope for a single medical report.
Won’t I end up with too many reports that are hard to combine?
No. A well designed clinical template software will support “bringing forward” data from earlier reports, reducing re-entry and ensuring patient records are consistently complete. It will also support combining case information from multiple reports into summaries for specific readers like referring specialists and family caregivers.
Clinical Template Software
When implementing clinical templates, it’s important to choose synoptic reporting software that enables you to conveniently configure clinical templates and update them as care pathways and best practices evolve.