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Whether you are a multi-facility health system, critical access hospital, single-specialty or multi-specialty ambulatory clinic, or an outpatient surgery center, standardization of your clinical content is well worth considering. It doesn’t matter which EMR software you use, or where you are in the process of implementation/upgrading/optimizing, the benefits of standardization far outweigh not doing so.

What is clinical content standardization? In the simplest terms, it is the process of creating a limited content library for things like order sets, note templates, and formularies. It may also include items often considered chart etiquette such as SOAP vs. APSO note format and whether specific data points can and should be pulled into the documentation.

Clinical content standardization works to drive value-based medicine. One admission order set for each presenting problem supports best practice and consistent care. Organizations that have implemented this approach have not only decreased costs, but they have also reduced length of stay and improved patient outcomes.

Standardizing note templates by either collapsing the S and O sections of the progress note or adopting the APSO format and limiting the “routine” addition of patient results within the progress note, leads to better communication between team members. The recent trend toward “note bloat” has led to significant team member dissatisfaction as they try to quickly scan notes and understand what the provider is considering and recommending. Having a standard format is also helpful when searching a note for a specific piece of information. The reader knows exactly where to find what they are searching for.

Formulary standardization limits the number of medications a team has to possess expert knowledge of. When standardized, the systems allow for equivalent substitutions. This strategy yields cost savings through contracting and limits waste due to expiration.

For each of the examples above, there is an additional benefit. One can build just about anything given enough money, time, and effort. However, maintaining and updating the build to be current can be daunting when systems are not standardized. Analysts can spend most of their time managing the current build leaving little time to enhance or optimize the EMR to serve the needs of the end-user. Standardizing can give teams a chance to look ahead and work proactively to optimize the EMR.

I’ve spent my career helping organizations standardize their clinical content. Admittedly, it does take a concerted effort and attention to detail, but it is well worth it. My experience has shown that less than 200 order sets are necessary for any large health system. Standardization requires vision, leadership support, and a team willing to engage content champions in the process of reviewing and modifying the content. This process is most effectively done through your normal governance structure, utilizing those closest to the work to recommend the changes and having those in leadership as the points of escalation for areas of controversy.

If this resonates with you, wherever you are on your journey, start! You may not be able to change it all at once, but making small changes over time is like the concept of compounding interest. Before you know it, you will have made significant changes in your EMR. Providers will be happier, you will be saving money, and patients will be getting better care.

If you are interested in learning more about how Optimum Healthcare IT can help you standardize your clinical content, click here.

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