Abstract:

Clinicians and health care providers rely on information collected during encounters with patients for diagnosis and treatment plan decisions. The quality and reliability of patient encounters is the primary factor impacting the quality of care. Consequently, one of the main challenges in the training of health care providers is to teach how to get appropriate documentation, using standardized and universal language. Health practitioners training is generally done under the supervision of an expert that reviews the data collected and decisions made during patient encounters. Electronic Health Records (EHR) systems have been developed to help clinicians collect and store health data, and are used to facilitate electronic charting, support interprofessional practice communication in health care teams. EHR systems are an integral part of ensuring high standards of care and they are used to train health practitioners (residents, students and clinicians). The benefits of real-time information to optimize timely and informed clinical decision-making are well documented. EHR has a significant potential to accelerate quality improvement (QI) and research initiatives directly focused on transforming clinical care, patient outcomes and health services efficiency. However, because EHR systems are generic professional software applications they lack the needed pedagogical features and must be customized for particular fields of application. The Orofacial Pain and Oral Medicine (OFPOM) Clinic at the Herman Ostrow School of Dentistry of the University of Southern California receives patients that are evaluated and treated by residents under the supervision of faculty experts. In this paper we describe how the Clinic has developed its own custom EHR system to teach residents and improve the performance to perform efficient and accurate diagnostics and treatments. We elaborate how, while the system is specifically targeted to the OFPOM domain, the process and lessons learned are directly useful to other medical fields. In particular we detail the design considerations, the development process and evaluation. We believe that more accurate data, obtained from the interview between the residents and the patient, will lead to improved patient outcomes through more accurate diagnostic and better treatment choices. Another key benefit of the system is a simplified workflow with centralized data that helps decrease medical errors and clinician efficiency and experience. This article describes the process for developing a customized EHR for the OFPOM Clinic as a tool for teaching residents and to optimize patient care by improving the quality of the data obtained during patient interviews.

Keywords:

Electronic Health Record, Orofacial Pain, Oral Medicine, Diagnosis, Treatment, Efficiency.