AT EMR OPTIMIZATION 1

Program Capstone: Optimization of an Athletic Training Electronic Medical Record

Patrick Langit

University of San Diego

Advisor: Brenda Boone, PhD, RN, CRN

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Executive Summary

Athletic trainers (ATs) are specialized healthcare providers who traditionally provide

management and care of acute and chronic physical injuries, in a physically active patient

population. Due to a varying landscape in documentation strategies in the profession, many ATs

still rely on paper only or a combination of paper and electronic based documentation to record

and store patient information. Having multiple mediums for recording patient information can

create opportunities for waste and gaps in care, some of which that can result in patient harm.

ATs who have invested in an electronic medical record (EMR) often have yet to realize its many

benefits due to poor adoption strategies or a lack of documentation workflow analysis and

process improvement initiatives. This project involved the optimization of EMR use in a

traditional collegiate athletics sports medicine clinic. The previous environment of the clinic

featured a mixed model of paper and electronic based documentation. A lack of standardized

procedures, training, and documentation oversight created problems that prevented the efficient

documentation and facilitation of care among the ATs and their patients. Analysis of workflow

and subsequent process mapping was performed to outline appropriate documentation

procedures. The improved procedures created opportunities for data analysis to guide clinical

decision making. In addition, an educational training program on expectations for and

appropriate use of the EMR was created. Project outcomes yielded an increased reliance on the

EMR for clinical documentation, the standardization of documentation workflows and an

increased comfort level of ATs’ interaction with the software. As there continues to be a need to

strengthen EMR adoption and optimization in athletic training, future projects should include

objective measurements to understand the overall impact of these implemented changes on

documentation efficiency and quality.

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Optimization of an Athletic Training Electronic Medical Record

Athletic trainers (ATs), as like other allied health providers, must maintain high-quality

and accurate documentation for all patient encounters (National Athletic Trainers Association,

n.d.). Unfortunately, many ATs in athletics settings still rely on traditional, paper-based

documentation and medical record storage. Although increasing evidence within the profession

advocates for widespread electronic medical record (EMR) adoption, challenges such as lack of

guidance and time continue to persist as strong barriers to this task (Bacon et al., 2017). An

EMR is an interactive software utilized by healthcare professionals to document their patient

interactions as a means of guiding care (Evans, 2016). Legislation such as the Health

Information Technology for Economic and Clinical Health (HITECH) Act of 2009 have been

pivotal in supporting healthcare organizations (HCOs) to invest in and adopt EMRs due to their

ability to facilitate real-time documentation of patient care (Marshall & Lam, 2020). By

streamlining access to meaningful and reliable patient information, EMRs have proven to be an

effective medium for supporting evidence-based medical practice and expanding the patient-

provider relationship (Marshall & Lam, 2020).

Adoption and optimization of an EMR can yield many benefits including improved

documentation security, facilitation of consistent patient care across an interdisciplinary team,

integration of clinical decision support tools, and the potential to improve documentation

workflow efficiency (Janett & Yercaris, 2020). The profession of athletic training features

elements common to other healthcare professions, such as physical therapy, orthopedics, and

emergency medical care. Because these responsibilities are accompanied by many

opportunities for patient interaction, upholding documentation standards that ensure the

management of reliable and accurate health information is imperative. Although existing EMR

software in the profession is currently limited, they nonetheless have the capability to store and

maintain patient information in a highly organized and easily accessible manner. Knowledge on

EMR adoption and optimization within the profession is unfortunately limited leaving many ATs
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without having realized the benefits of EMR use and a resort to workarounds and inconsistent

documentation practices (Bacon et al., 2018). Therefore, as ATs strive to deploy innovative

means to maximize patient care, further investigation of optimizing EMR usage in the profession

is warranted.

This comprehensive project served as an opportunity to apply concepts in process

improvement and data management to the electronic documentation of health information in the

field of athletic training. The purpose of this project was to evaluate and improve on the current

environment for EMR use in a traditional athletic training environment within a university setting.

After careful review of documentation-based workflows and provider interactions with the

respective EMR, clinical decision support tools were designed and implemented to guide the

improvement of documentation practices and the provision of care. The goal of this

comprehensive project was to streamline and optimize the interaction and use of the EMR to

guide effective care and future injury prevention initiatives.

Statement of problem

As EMR dependence in athletic training has changed over time, it was vital to capture

and understand the current practices in electronic documentation at the target setting to identify

previous gaps in information management quality. For this project, focus was concentrated on

ATs and their interaction with a sports medicine based EMR system. The clinical setting was a

sports medicine facility at a private university that is recognized athletically by the National

Collegiate Athletic Association (NCAA). The patient population was comprised solely of student-

athletes (SAs) who attended the university and actively participated in university sponsored

NCAA Division 1 athletics.

The EMR utilized by the clinic, Sportsware Online (SWOL), is specific to the profession

of athletic training and has been endorsed by many collegiate athletic settings across the U.S.

The software has the capability to guide and store documentation for common needs in athletic

training such as orthopedic conditions resulting from athletic injury, general medical conditions,
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mild traumatic brain injuries, annual preparticipation sports physical examinations, surgeries,

and the treatment of existing conditions. Reporting options within SWOL also allowed for the

extraction of data into .xls files or pre-set .pdf templates. Additionally, SWOL can be used to

facilitate communication to athletes, parents (for those under the age of 18), and athletics

coaches by deploying specific portals for each of these individuals.

Prior to project implementation, the clinic had used SWOL for a total of six years, at what

appeared to be at a superficial capacity. To the knowledge of the existing ATs, the adoption of

SWOL did not include any workflow analysis or customization specific to the team’s needs by

the vendor. Implementation occurred remotely and no on-site training was provided to the

clinical staff. Education for the utilization of SWOL occurred virtually by way of scheduled phone

calls and self-directed learning with the support of training videos provided by the vendor. The

absence of a guided adoption specific to the needs of the clinic already introduced an

atmosphere that was likely lacking in feelings of support, ineffective system use, and confusion.

Lack of confidence among the ATs resulting from a poor EMR implementation may have

contributed significantly to an absence of buy-in and minimal movement away from paper-based

documentation.

The previous climate for clinical documentation prior to this project was a mixture of

paper and electronic-based documentation. Clinical encounters such as follow up appointments,

rehabilitative and therapy sessions, and injury evaluations were heavily reliant on paper

documentation and handwritten notes. This proved to be problematic for many reasons. First,

differences in handwriting created many problems in the appropriate interpretation of a

diagnosis or plan of care. Illegible handwriting resulted in misinterpretation of a patient’s plan of

care leading to medical errors and patient harm. Paper documentation also held a higher risk for

the breach of information security as records had the potential to be lost or damaged.

Secondary to this potential violation was that incomplete records prevented the AT from

understanding the patient’s history and could severely affect continuity of patient care. In
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addition, the physical record storage via a filing system limited access to pertinent patient

information at the point of care which hindered care delivery. The reliance on paper

documentation within the clinic also offered no opportunities to guide care. EMRs have the

capability to embed clinical decision support tools and draw reports based on quantifiable data

entry to support clinical decision making (Janett & Yeracaris, 2020). The data collected from

computerized entry could also be further used to study specific trends and justify future

interventions to improve care quality and patient safety (Janett & Yeracaris, 2020).

Prior to this project, SWOL was heavily underutilized and only a few features were

utilized for documentation. As aforementioned, this may have been due to a lack of training and

knowledge by the ATs. All interaction with the online software was by the ATs. Patient portals

were not deployed for registration or communication. Instead, basic patient demographics such

as name, date of birth, sport and graduating class were collected and input via paper pre-

participation forms submitted by the SAs. Initial injury evaluations were recorded by way of

open-field text on SWOL and follow up evaluations were documented in combination with daily

rehabilitation plans on paper. This workflow was highly ineffective because ATs were having to

sift through both paper and electronic records to understand the patient’s progress after an

injury. Lastly, ATs were given the option to utilize the treatment feature in SWOL to plan, list,

and track patient rehabilitation plans. ATs who elected to not use SWOL for recording

treatments instead used an outlined paper document for the same purpose. This lack of

standardization created inconsistent storage of patient treatment and progress which was

problematic specifically if a SA were to see a different AT on consecutive days.

In the selected clinical setting, a total of nine Certified ATs (six full-time employees, three

part-time employees) utilized SWOL to document patient interactions. EMR access was also

granted to seventeen athletic training students with limited privileges. These limitations

prevented AT students from altering or deleting any existing data within the system but allowed

for data entry in certain areas. As the patient population consisted solely of SAs there was
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consistently between 450 and 500 individuals who ATs were responsible for. The available

hardware for use included six desktop computers, two portable laptop computers, and one

tablet and hardware upgrade or purchase was not to be part of the project. The clinical staff

accessed the EMR via an internet browser, which was connected to a university wide Wi-Fi-

network with access protected by two-factor authentication.

In the previous environment, there was also no formal training program or oversight on

the education of expected documentation standards to the ATs in the sports medicine

department. However, one annual presentation by a designated AT was provided via a large

classroom lecture to discuss commonly used features of the EMR along with a demonstration of

basic documentation workflows. The lack of an organized training program and environment

was thought to be a barrier to the establishment and enforcement of standardized

documentation procedures.

After careful analysis of the existing environment prior to deployment of the project, it

was clear that an intervention was needed. The absence of standardized workflows left major

gaps in care continuity and enabled opportunities for patient harm. Mixed methods for recording

of data and health information heavily limited access to pertinent information at the point of care

and made it difficult to locate specific information (i.e., magnetic resonance imaging results,

surgeon rehabilitation protocols, and patient progress notes) needed to deliver care. In the

previous environment, underutilized features in SWOL created a large amount of waste that

could have been prevented with appropriate guidance. It was the hope that with an organized

and tactical approach, tools embedded in SWOL could be used to support custom and

standardized workflows tailored to the needs of the ATs.

PICOT Question

The utilization of an overarching clinical research question to guide activities within a

project is crucial towards project success. The clinical research question for this project will

follow the “PICOT” format to best outline the patient, intervention, outcomes, projected time
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frame, and a population or standard on which to compare the intervention with (Dang &

Dearholt, 2018). Thus, the following clinical research question was used to guide this project:

How can ATs in the collegiate athletics setting utilize EMR adoption and optimization strategies

such as: improving documentation workflows, establishing a thorough EMR training program,

enforcing a uniform means of managing health data, and using accurate data analysis methods

to improve clinical documentation, patient care quality, and clinical decision making when

compared to paper-based documentation?

Review of Literature

Recognized by the Department of Health and Human Services as healthcare providers,

ATs are upheld to the same patient care standards as other allied-health professionals (National

Athletic Trainers Association, n.d.). This includes not only in the actual provision of care, but in

the proficient documentation of patient encounters that helps ensure safe practices and

strengthens care continuity. As a result, having established documentation practices is crucial

not only to meet standards of care in athletic training, but to support high quality care and

protect ATs from litigation. Additionally, fluid communication supported by good documentation

between providers of an interdisciplinary team can help facilitate accurate patient management

and treatment measures congruent with a patient’s short and long-term goals (NATA, 2017).

The field of athletic training is a highly specialized medical profession and requires

extensive knowledge and skill in the evaluation and rehabilitation of athletic injuries and general

medical conditions. ATs must have a thorough understanding of healthcare systems as they are

involved in every step of healthcare provision, both as a provider, and in navigating access to

advanced care with their patients (Rotenberg, 2017). As healthcare continues to encourage

holistic patient care via multi-disciplinary teams, the AT has become even more crucial in

bridging the gap between the patient and medical resources needed to achieve treatment goals

(Nottingham et al., 2017).

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Guidelines and standards of ethical practice for ATs set forth by the National Athletic

Trainers Association (NATA) specific to clinical documentation demands for timely and secure

recording of all patient interactions (Bacon et al., 2017). However, many challenges and

perceived barriers within the profession can make clinical documentation arduous for the AT.

The inconsistencies in documentation can lead to fragmented patient care and make the AT

susceptible to litigation. Challenges of time requirements for documentation, unclear

documentation expectations, and lack of resources have all been reported by ATs as primary

barriers to concise and appropriate documentation practices (Bacon et al., 2017). ATs can be

seen providing patient care across a variety of clinical settings, some of which include

professional athletics, collegiate athletics, youth sports, outpatient physical therapy clinics,

physicians’ offices, performing arts, military, and performance and wellness centers. As each

setting features its own unique demands and documentation workflows, this review will focus on

the most traditional and common work setting for ATs, which is within competitive and organized

athletics.

Provision of healthcare within competitive athletics by ATs bears many differences from

traditional healthcare settings that directly relate to the aforementioned barriers to

documentation. For example, due to the needs of SAs who have injuries and conditions that

must be evaluated and treated regularly, it is very typical for an AT to have multiple clinical

interactions each day. The number of daily encounters can also grow if an athlete sustains

multiple injuries, thereby requiring additional therapy and treatment. Because AT services are

seen as a benefit for athletes provided by the educational institution, multiple interactions are

customary, and access is not bound by insurance pre-approval or billing. Consequently,

expanded access to services increases time spent treating and evaluating patients and can

therefore create a time constraint on ATs in fulfilling documentation requirements (Bacon et al.,

2017).
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To help guide health care organizations (HCOs) in establishing standards of care, the

Institute for Healthcare Improvement (IHI) has developed the Quadruple Aim. In the Quadruple

Aim, the IHI highlights: improved population health, a high-level patient care experience, lower

health care costs, and high provider satisfaction as drivers of care for HCOs to consider (IHI,

2017). When analyzing the Quadruple further, cost is seen as a significant factor to healthcare

access and influences overall population health and patient care experience (Feeley, 2017). For

ATs, cost is not an issue for the patient which can inversely improve the outlook on care

experience. However, increasing access without having appropriate staffing and resources can

also place a substantial load on the provider’s satisfaction. This fourth facet of the quadruple

aim for ATs becomes affected by a high volume of interactions per patient, difficulty to provide

proficient documentation, and risk for provider burnout (Bacon et al., 2018).

This challenge is further expounded by high patient to provider ratios. In secondary

school and collegiate athletic settings, ATs are often responsible for overseeing the health of all

athletes in multiple teams (Bacon et al., 2017). These high patient populations create situations

where the AT must treat multiple patients simultaneously to meet the demand for care.

Unfortunately, these challenging circumstances places a large burden on ATs to document

patient encounters from memory due to the inability to document immediately after each

interaction. Furthermore, the quality of care and amount of provider to patient facetime in the

simultaneous management of multiple patients may also be called into question. Ultimately,

limited staffing with unrestricted access to care culminate to a lack of time to regularly fulfill

documentation expectations (Bacon et al., 2018).

Additional perceived barriers to clinical documentation specific to ATs include the

absence of standardized documentation procedures and a general lack of knowledge regarding

components of high-quality documentation (Bacon et al., 2018). In 2017, the National Athletic

Trainers’ Association (NATA) released the Documentation and Coding Best Practice Guidelines

which provided general recommendations on appropriate clinical documentation of patient

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encounters for ATs. Within these guidelines, ATs are reminded of the importance of

documentation and its role in facilitating management of patient care, and in providing a record

of evaluations, treatments and interventions performed with a patient across all involved

clinicians (NATA, 2017). The NATA also endorsed the appropriate use of medical terminology

(and respective abbreviations) within clinical documentation of patient encounters and

emphasized that informed consent is documented and maintained throughout each interaction

(NATA, 2017). EMRs are also recognized and endorsed by the NATA as an effective medium

for capturing patient information in real time. Highlighted advantages include immediate access

to records in a secure manner to maintain care efficiency, reduction of medical errors, improving

interactions and communication between ATs and their patients, and the promotion of complete,

accurate and legible documentation of patient health and status (NATA, 2017).

However, even with this guidance, many ATs report feelings of a lack in the enforcement

of these expectations from a regulatory agency, resulting in ambiguous documentation practices

(Nottingham et al., 2017). The lack of strict enforcement and federal sponsorship of

documentation guidelines outside of the NATA also feeds into inconsistent documentation

practices across the profession (Eberman et al., 2019).

These many challenges contribute to the lack of EMR adoption across the profession.

Although there is a reported belief among ATs that EMRs are effective and efficient, there are

co-existing barriers that hinder its acceptance and optimization (Bacon et al., 2018). Despite

receiving support from organizations such as the Athletic Training Strategic Alliance, confusion

among proper EMR adoption and optimization in athletic training remains (Marshall & Lam,

2020). Much of this confusion may be due to a lack of training and access to professionals who

are knowledgeable in EMR specific process improvement. Therefore, ATs must familiarize

themselves with the appropriate standards for EMR use and the capabilities of their EMR to

best support their clinics.

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Although EMRs are marked as essential to transforming healthcare, unsatisfactory

adoption efforts are likely a result of poor analysis of interactions between end-users and

technology (Bowman, 2013). It is vital that project managers (PMs) have a complete

understanding of the EMR system and functionality for their specific settings. Doing so helps

prevent usability errors and documentation workflow incompatibility (Bowman, 2013). To

capture EMR usage through the patient’s experience, workflows must also be considered

across all end-users who interact with it at the pre, during, and after visit phases of care (Janett

& Yeracaris, 2020). With regards to build, PMs should work with team analysts and their EMR

vendors to maintain consistency in data entry options and placement. Data entry should be

streamlined and avoid any opportunity for gaps or fragmentation in documentation or care

delivery (Janett & Yeracaris, 2020). For example, structured data entry fields such as drop-down

menus should remain consistent across similar situations and avoid the intermixing of open-field

text opportunities (Bowman, 2013). These considerations should also include the careful

placement of data entry fields to minimize any redundancy and other mechanisms of process

waste. Consistency of ethical documentation practices must also be supported with

organizational policy that defines the appropriate methods and expectations (Bowman, 2013).

As EMR adoption continues to receive strong support in the field of athletic training, ATs should

consider these strategies and standards for implementation and optimization.

Goals, Objectives, Purpose

The primary goal of this project was to improve documentation practices in a manner

that was safe, efficient, and that would lead to informed clinical decision making within a

collegiate sports medicine facility. It was the hope that after careful analysis and revision of

specific clinical documentation workflows, the analysis of recorded data to drive clinical

decisions and improve patient care and outcomes would become successful.

The purpose of this project was to create processes and tools that would improve the

longevity of documentation efficiency and accuracy within the department’s EMR. In doing so, it
AT EMR OPTIMIZATION 13

was anticipated that perceived barriers between ATs and EMR usage would be either reduced,

minimized, or eliminated, ultimately leading to an improved clinician experience. Furthermore,

streamlined workflows were predicted to help control patient flow through the clinic by

decreasing wait times, increasing patient to provider face to face interaction, and improving the

overall patient care experience.

Objectives for this project include increasing clinician satisfaction with EMR usage,

improving the storage and access of patient information, standardizing documentation

workflows specific to patient evaluation, follow-up, treatment, decreasing the mental burden of

documentation requirements through the generation and installation of clinical decision support

tools, developing a training program to guide and train clinicians for appropriate EMR usage,

and analyzing stored data to help make evidence-based decisions for patient care within the

sports medicine department. Collectively, these objectives should create a cultural shift by not

only migrating the clinic’s EMR use towards optimization, but also empowering clinical staff to

seek continuous improvements in EMR usage to better facilitate documentation and care.

Scope of Work, Plan of Action, Activities

As this project served as a culmination of an improvement and standardization in

documentation workflows and clinical documentation tools, it was vital that activities and tasks

were carefully planned and executed in a timely manner. This author was the PM and practiced

as an AT within the department. In conjunction with the existing organizational chart, this author

reported directly to the Director of Sports Medicine for project approval and working status.

Initiation of the project began with defining the project purpose, goals, objectives. Next, key

stakeholders were determined due to their vitality for guiding surveillance, communication, and

appropriate outcomes. Key stakeholders included the ATs, direct patient population (university

scholar-athletes), sports medicine interns and students, team physicians, and the Director of

Sports Medicine.
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Project Planning

Project approval by the Director of Sports Medicine triggered the beginning of the project

planning phase. During this segment, a tentative project schedule was developed, and resource

requirements were determined. As this was the first project of its kind for the sports medicine

facility the target timeline for project completion was generously set for 2.5 years. The generous

project timeframe allowed for flexibility in completion of more arduous tasks and activities such

as process map development and analysis as well as the development and integration of

documentation tools. It was determined that this project would involve the existing EMR system

and there would be no changes in hardware resulting in no resource requirements outside of

time and labor. Lastly, appropriate lines of communication regarding project status and

participation with the project sponsor (Director of Sports Medicine) and the AT staff were

outlined.

Project Execution

The project execution phase began with an assessment of the current state of EMR use

in the clinic. This was the first-time workflows would be documented and captured on a process

map for this department. Therefore, all ATs were encouraged to actively participate in one-on-

one interviews and staff meetings to voice their opinions and contribute to an accurate depiction

and collective understanding of existing EMR interactions. Common themes noted from these

meetings included non-uniform documentation practices, concerns about the integrity of patient

files in the current mixed paper and electronic format, the need for guidance and training for

each type of clinical interaction, and the desire to analyze collected data to understand injury

occurrence within the patient population. It was for these reasons that this project was justified,

and unanimous support was granted from all ATs.

Previous State Workflow analysis. Existing workflows for patient evaluation and

treatment documentation were translated into a current state process map which was generated

by the PM through use of the Microsoft Visio software. Feedback from clinical staff was obtained
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again through one-on-one and team meetings following the presentation of the process maps.

Upon a department wide consensus regarding the existing workflow and the developed process

maps, the overall value of each activity was scanned for potential sources of waste, such as

waiting time, unutilized skill, defects, and extra processing (GoLeanSixSigma, 2021). Identified

gaps within the workflows were identified and possible solutions to remediate those

shortcomings were discussed. For example, in the previous state process for injury evaluations,

patients were permitted to arrive at the clinic as they pleased which created many opportunities

for wait time, overcrowding and unnecessary movement (Figure 2). In a clinic with a total of

seven examination tables and nine ATs responsible for overseeing the health of 450 SAs, lack

of control in patient flow resulted in opportunities for overcrowding, excessive movement of

within the clinic, and high levels of strain to the ATs. This also resulted in two unnecessary

decision points in the workflow, and the improper utilization of talent as providers would have to

waste time and energy in coordinating patient movement instead of focusing on patient care

(Gay, 2016).

An additional concern was that ATs were having to rely on memory and resort to

unguided execution of patient evaluations to document their interactions from. These

inconsistent evaluation procedures consequently led to inaccurate and highly variable

documentation and examination practices within the department. These variances between ATs

also created avenues for miscommunication in patient hand-off situations thereby deterring from

the provision of consistent and optimal care. Therefore, it was determined that the lack of an

established protocol permitted the inability to meet the desired standards of documentation and

information management needed to facilitate safe and efficient care.

The previous state process for documentation of treatment plans (Figure 3) faced similar

issues that were exacerbated by this workflow’s input being heavily reliant upon the accuracy

and availability of information after an evaluation. As with evaluations, sources of process waste

were enabled with a lack of controlled patient flow through the clinic. Therefore, a patient’s
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ability to be taken care of was dependent on the availability of both the AT and space. Once a

patient was seated, the ability to move forward in the process was contingent on successful

documentation of the patient’s initial evaluation. With an environment that relied heavily on

paper documentation, many opportunities for error such as illegible handwriting, misplaced

documents, and inconsistent charting delayed the provision of care. This ultimately damaged

the patient’s experience and rapport with the ATs.

Patient visits for treatment were also an opportunity to provide progress notes on the

patient’s health status. This too, however, was an additional process that was dependent on the

output of an evaluation. If a patient’s condition was not accurately transcribed into the EMR from

the paper documents, there was no ability to build on the patient’s record. There was also no

uniform structure for the performance of follow-up evaluations and documentation of progress

notes and again ATs would be reliant on memory or unstructured open note documentation on

paper.

Development of Solutions

Collaboration with EMR Vendor. After careful analysis of current state processes,

solutions based on the identified gaps were formulated in accordance with the project goals and

objectives. Through collaboration between the PM and the EMR vendor, customization options

and recommendations for efficient navigation through the EMR were determined based on

department needs. The PM coordinated virtual meetings with the EMR vendor representative

where concerns of patient safety and underutilization of the EMR were presented. These issues

were also supported with barriers of lack of technical support and adoption guidance reported

by the AT staff that affected reliance on the EMR. The previous state process maps were

presented to the vendor along with an explicit description of the end goal and vision for the

project to standardize electronic documentation for all clinical interactions. Solutions

recommended by the EMR vendor encouraged the tailoring of processes and use of features

built into the software to fit the needs of the ATs. A detailed walk through was performed with
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the PM across each area of the EMR with structured and unstructured documentation field

options according to the information that was needing to be captured. Customization options did

not include changes in build of the interface but did allow for the altering of some data entry

fields for recording information pertaining to specific injuries and treatment modalities. Although

software customization was limited, this process allowed the PM to develop a thorough

understanding of the overall system functionality. The PM was then able to re-strategize

procedures for data entry that would record the necessary information within the patient’s record

at each step of the target processes.

Revision of Workflows. As aforementioned, in the current state workflow, ATs

documented interactions by a combination of paper and electronic means. This documentation

was not guided and was entered within the EMR via open-field text which yielded no opportunity

for quantitative analysis of data. Examples of data variables that the ATs would have liked to

measure included injury rates by team and position within team, flow of patients in the clinic in

one day, distribution of injuries within each team, average number of participation days lost due

to a specific injury, and cost savings resulting from direct therapy prescribed in the clinic. Open

text data entry also led to inconsistencies in documentation of evaluations and treatment which

affected continuity of care across ATs. The variance in documentation and data entry resulted in

not only extra time needed to interpret and understand each patient’s condition, but risk

incomplete documentation and understanding of the diagnosis and treatment plan. The revised

workflows for documentation of evaluations and treatments were created to establish a

standardized process to be used by all clinicians. The new workflow also called on the

department to lean on their EMR system to utilize areas within the patient chart that could both

capture necessary information and quantify it into meaningful data. Examples of these data

entry fields included drop down menus for the mechanism of injury, location of injury, body part,

side of body, and diagnosis with respective ICD-10 code. For treatments, drop down menus to

categorize modalities such as therapeutic exercise, manual therapy, electrical stimulation, and
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ultrasound were used in combination with CPT codes to capture hypothetical billing costs (as

athletic training services are not billed through insurance) and organize treatment plans.

Creation of Clinical Decision Support Tools. To guide evaluations and progress

notes, tools in the form of documentation templates were created to strengthen a consistent

documentation process that could capture additional information. Customization options for the

EMR was very limited and therefore, the created templates (Figures 6 & 7) would be copied into

the patient chart and completed during an appointment. It was understood that this method

would not yield data that could be used for analysis, however the benefits of using templates

ensured uniform documentation, and guided evaluations at the time of the appointment ensuring

that all pertinent segments are carried out to obtain the most accurate diagnosis and plan of

care for the patient. The templates followed the Subjective, Objective, Assessment, and Plan

format (SOAP) that was recommended for use in athletic training by the World Health

Organization (Ebermen et al., 2019). The SOAP format is commonly used by many allied health

professions leaving variability and therefore the template was further strengthened by

incorporating the Cyriax System of Orthopaedic Medicine which is used for the objective

evaluation of sports-based injuries (American Academy Association of Orthopedic Medicine,

n.d.). This evaluation method attempts to identify a specific condition based on testing that

considers human functional anatomy and movement. Under this system, the clinician uses the

assessment of active and resisted range of motion to test muscular strength and passive range

of motion testing to evaluate ligament integrity injuries (American Academy Association of

Orthopedic Medicine, n.d.). With an understanding of what movements can stress specific

structures, the hope is to identify the exact location of a musculoskeletal lesion in the body.

Review and Pilot Testing

Once each tool and proposed adjustment in workflow was finalized and agreed upon by

the Director of Sports Medicine and the ATs, process maps were adjusted and updated to

reflect the changes made. Updated process maps were presented to the department and
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agreed upon prior to a pilot test. A pilot test was conducted with the Director of Sports Medicine

for each of the workflows over a period of one week. Findings led to no immediate adjustments

to the workflow, therefore the workflows were deemed ready for go-live. Prior to go-live, a

department training session was held where the PM reviewed the implemented changes and

guided each AT through the new workflows. Guidance was provided with copies of the updated

process maps, tip sheets, and screen recorded demonstrations of the new workflows.

Go-Live

Go-Live incorporated the full immersion of the new workflows in evaluation, follow-up,

and treatment documentation. The PM served as the on-site trainer to assist clinicians at the

elbow and support to the go-live phase. As the new workflows enabled data collection by way of

utilizing data entry fields in lieu of open-field text, the PM was able to extract data from the EMR

and perform analysis to address clinical questions from the AT staff. The PM extracted the data

into a Microsoft Excel compatible spreadsheet and after appropriate cleaning, was able to

produce basic visualizations. For example, a bar graph was used to compare the distribution of

injuries for the volleyball team across two separate seasons (Figure 8). The PM also transferred

spreadsheets from Microsoft Excel into Microsoft Access. Here, the PM created a preliminary

database containing two years of data from the EMR. Tables were designed to display

observations for variables, such as injury, date of injury, days of participation missed due to

injury, team, and position. A relational database was created from the tables to prepare analysis

by way of structured query language (SQL). SQL is a computer-based language used to

organize, manipulate, and obtaining information across variables in a relational database

(Knight, 2017).

Data Extraction and Analysis

In this project, SQL was used to begin understanding preliminary data trends such as

injury occurrence within sport and across positions within each sport (Tables 1-3). Findings in

the data were presented to the Director of Sports Medicine to guide future injury prevention
AT EMR OPTIMIZATION 20

initiatives. Additional activities during this “Monitor & Control” phase included obtaining feedback

from the ATs on the implementation of the new documentation workflows. Feedback was

gathered from individual meetings with ATs, as well as from group discussion during team

meetings. Outcomes from these meetings yielded a thorough understanding of the purpose for

the implemented change and an improvement in the exchange of patient health information

across clinicians. Constructive feedback provided by the end-users was focused on a better go-

live approach for implementation of future projects. Staff expressed feelings of anxiety with the

overload of information required to adapt to changes in multiple documentation workflows. One

additional area that staff expressed desire in addressing for future projects is for the opportunity

to have a more extensive and formal training on the changes prior to implementation.

EMR Training Program Development

Although not included in the original project plan and schedule, training material was

developed to support the improved workflows and prepare for appropriate education of future

staff. As marked in previous large scale electronic health record adoptions at HCOs, lack of

technical support and adequate training has been labeled as primary barriers to adoption (Kruse

et al., 2016). Therefore, it was decided by the PM to produce a structured program to educate

ATs on expected use of the EMR. This was a very important segment of the overall project as

supporting and training end users is known to be crucial to an EMR implementation and can

improve provider satisfaction while simultaneously protecting patient safety and care quality

(Pantaleoni et al., 2015).

All training materials were developed by the PM with goals of supporting end-user EMR

use and improving end-user satisfaction. To aid with troubleshooting documentation of clinical

encounters, physical tip sheets were created as reference guides for clinicians (Figures 9 &10).

Additionally, instructional videos were generated as a visual step-by-step guide to view on-

demand or place side-by-side during the data entry process into the EMR (Figures 11 &12).

These videos were also designed to be distributed to newly hired ATs during the onboarding
AT EMR OPTIMIZATION 21

process as a self-directed learning tool prior to formal in-person training sessions. As new hires

would be granted limited access to the EMR, they would be asked to complete short tasks

during or after watching these videos to promote early interaction with the software. Therefore,

these ATs can begin to affiliate themselves with navigating the software and bringing questions

to formal training sessions. Lastly, new hires would receive in-person training where they would

be guided through each documentation workflow and instructed on appropriate navigation of the

EMR. To maximize support and guidance, an appropriate student to instructor ratio would be

used. At the conclusion of the training, students would be presented with various scenarios

asking them to document specific injuries, evaluations, progress notes, and treatment of

patients. Mastery would be achieved and recorded upon a student’s ability to demonstrate

appropriate navigation and recording of data according to each scenario.

AT EMR OPTIMIZATION 22

Work Breakdown Structure and Gantt Chart Figure 1

EMR Optimization Project Gantt Chart

AT EMR OPTIMIZATION 23

Deliverables
• Workflow Analysis & Process Mapping

o Previous State Process Map for Documentation of Clinical Evaluations (Figure

A1)

o Previous State Process Map for Documentation of Patient Treatment Plans

(Figure A2)

o Revised Process Map for Documentation of Evaluations into SWOL (Figure A3)

o Revised Process Map for Documentation of Treatments into SWOL (Figure A4)

• Creation and Deployment of Clinical Decision Support Tools

o Clinical Evaluation SWOL Documentation Template (Figure B1)

o Clinical Progress Note SWOL Documentation Template (Figure B2)

• Management and Analysis of Data

o Sample Data of Injuries to Collegiate Volleyball Team Extracted from EMR

(Patient Identifiers Removed) (Table C1)

o Bar Graph Comparison of Injury Count Per Week During 2018 and 2019

Competitive Seasons for Volleyball Team Based on Extracted EMR Data (Graph

C1)

o Table of Total Days Out Due to an Injury according to Graduating Class in 2018-

’19 Academic Year (Table C2)

o Table of Total Injuries for Volleyball Team During 2018-19 Academic Year By

Position (Table C3)

• Education, Training, and Support

o Tip Sheet for Clinical Documentation of Evaluations into SWOL (Figure D1)

o Tip Sheet for Clinical Documentation of Treatments into SWOL (Figure D2)

o Self-Directed Learning Video for Clinical Documentation of Evaluations into

SWOL (Figure D3)

AT EMR OPTIMIZATION 24

o Self-Directed Learning Video for Clinical Documentation of Treatments into

SWOL (Figure D4)

Conclusion and Next steps

Although all objectives and goals were met with this comprehensive project, there were

many opportunities for improvement that should be implemented in the future. First and

foremost, this project was undertaken by one individual. Although the number of providers within

the clinic are low, it is of best interest to involve a team of individuals across various positions in

order to cover all perspectives of stakeholders. One example may be having a team that

involves one AT, one intern, and a team physician or organization administrator if indicated.

Although support was also obtained from the project sponsor and clinical staff, it may also be of

interest to include the patient population in communicating efforts and obtaining feedback post

go-live.

One of the many advantages for having a project team is the opportunity for idea sharing

and exchanging brainstorming strategies for determining optimal solutions to gaps in a process.

Spreading responsibilities across a team also creates ownership, which can translate to

department or organizational buy-in upon project implementation. Having a team actively

involved in a project such as this would have also been of great benefit when analyzing the

current environment surrounding EMR use. In this project, a current state process map was

developed to illustrate the existing workflows. However, a supplier, input, process, output,

customer (SIPOC) diagram would be more detailed and could have been a better approach.

The SIPOC diagram would allow the team to break down these high-level processes and have a

more in depth understanding of the process outputs, input requirements, and what potential

boundaries may exist (TECOEnergyInc., 2014). Having this additional knowledge could also

generate ideas for more optimal solutions where the effects are more easily seen across all

levels of a process.
AT EMR OPTIMIZATION 25

Another lesson learned with this project, is that it is vital to guiding change management

and monitoring post go-live measures is establishing and obtaining baseline measures. The

goals of this project were to increase efficiency, productivity, and accuracy of clinical

documentation as well as improvement of EMR end-user satisfaction by the clinic ATs. Though

there was positive feedback that yielded improved satisfaction and documentation consistency,

there were no baseline measures to compare with these claims. To truly understand the effect

of a project, measures used to determine goal achievement must be compared prior to and after

project implementation. In this project, a formal survey could have been deployed to collect

subjective data in a quantitative manner to measure EMR end-user satisfaction. Measures for

time in documentation of different patient interactions and overall interaction time with the EMR

could have also been implemented to determine documentation efficiency. These measures are

critical in understanding key performance indicators and the overall success of a project and

should not be ignored.

Future direction with this project should incorporate the annual re-assessment of these

documentation workflows (with the inclusion of objective measures) and develop value stream

mapping with these processes. Value-stream mapping is a great strategy to identify steps that

are value added and minimize non-value added steps (Pyzdek & Keller, 2018). In doing so,

project teams can improve process efficiency and maximize product value by making each step

more meaningful towards the final output. Nevertheless, ATs should prioritize maximizing value

by ensuring patient safety, improving provider satisfaction, and incorporating innovative means

to strengthen data integrity and accessibility in all EMR improvement projects.

AT EMR OPTIMIZATION 26

References

American Academy/Association of Orthopedic Medicine. (n.d.). Cyriax System of Orthopaedic

Medicine. https://www.aaomed.org/Cyriax-System-of-Orthopaedic-Medicine.

Bacon, C. E., Eppelheimer, B. L., Kasamatsu, T. M., Lam, K. C., & Nottingham, S. L. (2017).

Athletic trainers' perceptions of and barriers to patient care documentation: a report from

the athletic training practice-based research network. Journal of Athletic Training, 52(7),

667-675.

Bacon, C. E., Kasamatsu, T. M., Lam, K. C., & Nottingham, S. L. (2018). Future strategies to

enhance patient care documentation among athletic trainers: a report from the athletic

training practice-based research network. Journal of Athletic Training. 53(6), 619-626.

Bowman, S. (2013). Impact of electronic health record systems on information integrity: quality

and safety implications. Perspectives in health information management, 10(Fall), 1c.

Dang, D. & Dearholt, S. L. (2018). John Hopkins Nursing evidence-based practice: Models and

guidelines. (3rd ed). Indianapolis, IN: Sigma Theta Tau International.

Eberman, L. E., Neil E. R., Nottingham, S. L., Kasamatsu, T. M., & Bacon, C. E. (2019).

Athletic trainers’ practice patterns regarding medical documentation. Journal of Athletic

Training, 54(7), 822-830.

Evans, R. S. (2016). Electronic Health Records: Then, Now, and in the Future. Yearbook of

medical informatics, Suppl 1(Suppl 1), S48–S61.

Feeley, D. (2017). The triple aim or quadruple aim? Four points to help set your strategy.

Institute for Healthcare Improvement. http://www.ihi.org/communities/blogs/the-triple-

aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy
AT EMR OPTIMIZATION 27

Gay, C. (2016). 8 wastes of lean manufacturing. Machinemetrics.

https://www.machinemetrics.com/blog/8-wastes-of-lean-manufacturing.

GoLeanSixSigma. (2021). 8 wastes. Go Lean Six Sigma. https://goleansixsigma.com/8-wastes/

Institute for Healthcare Improvement. (2017, November 28). IHI’s position on the quadruple

aim. [Video]. Youtube. https://www.youtube.com/watch?v=d1uXN0WFcAY.

Janett, R. S., & Yeracaris, P. P. (2020). Electronic Medical Records in the American Health

System: challenges and lessons learned. Ciencia & saude coletiva, 25(4), 1293–1304.

Kruse, C. S., Kristof, C., Jones, B., Mitchell, E., & Martinez, A. (2016). Barriers to Electronic

Health Record Adoption: a Systematic Literature Review. Journal of medical systems,

40(12), 252.

Marshall, A. N. & Lam, K. C. (2020). Research at the point of care: using electronic medical

record systems to generate clinically meaningful evidence. Journal of Athletic Training,

55(2), 205-212.

National Athletic Trainers Association. (n.d.) Athletic training.

https://www.nata.org/about/athletic-training.

National Athletic Trainers Association. (2017). Best practice guidelines for athletic training

documentation. https://www.nata.org/sites/default/files/best-practice-guidelines-for-

athletic-training-documentation.pdf.

Nottingham, S. L., Lam, K. C., Kasamatsu, T. M., Eppelheimer, B. L., & Bacon, C. E. (2017).

Athletic trainers' reasons for and mechanics of documenting patient care: a report from

the athletic training practice-based research network. Journal of Athletic Training, 52(7),

656-666
AT EMR OPTIMIZATION 28

Pantaleoni, J. L., Stevens, L. A., Mailes, E. S., Goad, B. A., & Longhurst, C. A. (2015).

Successful physician training program for large scale EMR implementation. Applied

clinical informatics, 6(1), 80–95.

Pyzek, T. & Keller, P. (2018). The six-sigma handbook 5th ed. McGraw-Hill Education

Rotenberg, D. (2017, July 26). The role of the athletic trainer in patient-centered care. Board of

Certification for the Athletic Trainer. http://www.bocatc.org/newsroom/the-role-of-the-

athletic-trainer-in-patient-centered-care?category_key=at.

TECOEnergyInc. (2014, December 22). Lean methodology: the “define” phase [Video].

Streaming Service. https://www.youtube.com/watch?v=L1xyrixQmpQ&feature=youtu.be

AT EMR OPTIMIZATION 29

Appendix A

Workflow Analysis and Process Mapping

Figure A1. Previous state process map for the documentation of clinical evaluations.
AT EMR OPTIMIZATION 30

Figure A2. Previous state process map for the documentation of patient treatment plans.
AT EMR OPTIMIZATION 31

Figure A3. Revised process map for the documentation of evaluations into Sportsware
AT EMR OPTIMIZATION 32

Figure A4. Revised process map for the documentation of treatments into Sportsware.
AT EMR OPTIMIZATION 33

Appendix B

Documentation Templates for SWOL

Figure B1. Template for the documentation of clinical evaluations within SWOL following the SOAP and Cyriax System of
Orthopaedic Medicine.
AT EMR OPTIMIZATION 34

Figure B2. Template for the documentation of patient progress notes with SWOL.
AT EMR OPTIMIZATION 35

Appendix C

Analysis and Visualization of Data Extracted from SWOL Post Go-Live

Table C1. Distribution of injuries in a collegiate volleyball team extracted from SWOL from 2018-2019 (excluding patient identifiers)
AT EMR OPTIMIZATION 36

Graph C1. Bar graph comparing number of injuries per week during 2018 and 2019 competitive seasons for collegiate volleyball
team .
AT EMR OPTIMIZATION 37

Table C2. Database query reflecting total days out due to an injury by graduating class for the
2018-2019 academic year.

Table C3. Database query reflecting total injuries by position for a collegiate volleyball team
during the 2018-19 academic year
AT EMR OPTIMIZATION 38

Appendix D

Electronic Medical Record Training and Educational Material

SPORTSWARE – Evaluation Procedures

**Note: These procedures will use criteria for the Datalys/NCAA ISP reporting for all injuries. The
goal is to create a uniform reporting process that will improve data accuracy for both NCAA and
organizational reporting.

** Before inputting an injury, make sure the “Athlete Consent” under the Datalys section is marked
“Yes”. This will enable the Datalys fields to be active for that athlete. (This can be found within the
General tab of the athlete’s profile at the bottom right hand corner of the screen)

1) From the toolbar, select “INJ” (depicted with an ambulance).

2) Type in, or select the appropriate athlete from the “Select an athlete” dropdown menu/search bar
located at the top left section of the injury filter list.

3) Select the “ADD” button on the left-hand side of the screen to create a new injury file.
AT EMR OPTIMIZATION 39

4) Select/Input corresponding information for the below encircled & highlighted fields

+ Under the “Status” Box:

- Select the “Athletic” Box if the injury is athletically related
- Confirm the Injury Date and reporting time and Edit as needed.
- Select Return to Play Date (Once Appropriate)
o Return to Play = Date at which the athlete is allowed to participate in any
level of practice
- Select Closed Date (Once Appropriate)
o Closed = Date at which the injury is deemed as resolved
- Select only HIGHLIGHTED options under sport
+ Under the “Action” Box:
- Select the AT performing the evaluation
- Select the Appropriate action
- Select the Provider the athlete is referred to if applicable
AT EMR OPTIMIZATION 40

+ Under the “Description” Box:

- Under “Body Area” SELECT
ONLY HIGHLIGHTED OPTIONS
(Body Part, Environmental, or
System)

- Under “Body Part” select the appropriate body part being evaluated

- Under “Side” SELECT ONLY

HIGHLIGHTED OPTIONS (Bilateral,
Does Not Apply, Left, Right, Unknown)

+ LASTLY, Under the injury picklist filter, select the most accurate diagnosis category for the
evaluated injury along with appropriate severity (if applicable)

5) Under the “Background” tab, select the appropriate “Season” and “Surface” (highlighted below).

6) The “Attachments” Tab will be used to include any pertinent documents relating to the care of
that specific injury (i.e. Doctors visit notes, imaging results, PDF scans of Rehab sheets/protocols)
** When adding an attachment format the attachment name as follows:
Year.Month.Date_Last Name_ Body Part _ Type of Attachment_Provider
i.e.) 2020.06.01_Torero_L Ankle_ Initial Visit_Murphy
AT EMR OPTIMIZATION 41

7) Notes: Select “Add Note” and copy and paste the Initial Injury Evaluation Template

8) Datalys: Select/Input information for all highlighted areas below. (You may select “Sync with
Injury General Tab” to transfer over some previously entered information to the exposure event
record and injury detail records portion of the form)
- **NOTE: the Return Date input within the general tab will determine the available
outcomes. You must first set the return date before you can select an outcome.
AT EMR OPTIMIZATION 42

9) Finish by clicking “Save” at the top right section of the screen.

Figure D1. Tip sheet for revised clinical documentation of evaluations into SWOL.
AT EMR OPTIMIZATION 43

SPORTSWARE – Treatment Input Procedures

In order to improve data accuracy and to encourage a uniform documentation process, please
follow the following steps to input treatments within Sportsware.

1) Select the Treatment (“TRE”) Button from the tool bar (marked with 2 intercrossing
bandages).

2) Type in, or select the appropriate athlete from the “Select an athlete” dropdown menu/search bar
located at the top left section of the injury filter list.

3) Select the “ADD” button on the left-hand side of the screen to create a new treatment.

4) In the following screen **SELECT THE APPROPRIATE INJURY** to assign the treatment to
and click “OK”.

- If the treatment is a FIRST-TIME maintenance or preventative program, complete all fields

under “No Specific Injury”.
AT EMR OPTIMIZATION 44

- The Next time you input a preventative/maintenance treatment for the same body part it
will be found within Existing Injuries as shown below:

5) The General tab will appear. Complete the “Treatment” Box fields as applicable and as
highlighted below.
(Please try to keep the time consistent with when the SA reports to the ATR for treatment as this will
help with reporting and monitoring room flow)
AT EMR OPTIMIZATION 45

The “Injury” Box should confirm the selected injury which you are assigning the treatment to.

Complete the “Treatment Items” section by selecting appropriate treatments in the drop-down
menus and utilizing the corresponding comments space to give details about that
exercise/modality.

- You can edit your treatment list by using the “Add”, “Delete”, “Move Up”, or “Move
Down” functions on the left-hand side of the Treatment Items section.
- You may also use the “Save” button to store your specific treatment list as a
protocol to be used again later on. (May be helpful for body part and sport specific
maintenance programs. i.e. pitcher’s maintenance)
- You may use the “Load” button to bring up previously saved treatment protocols.

6) The Attachments tab may be used to attach/open any pertinent documents to the
corresponding injury file (i.e. rehab sheets, doc’s notes, ROI, etc.).
(Previously uploaded attachments will also appear here)

** When adding an attachment format the attachment name as follows:

Year.Month.Date_Last Name_ Body Part _ Type of Attachment_Provider
i.e.) 2020.06.01_Torero_L Ankle_ Initial Visit_Murphy
AT EMR OPTIMIZATION 46

7) The notes tab will hold all previously input notes for the athlete regarding the specific injury
being treated. Use the notes tab to complete a daily follow-up SOAP Note.
- Create a SOAP note regarding that day’s rehab in this field.
- You may also copy and paste the Daily/Progress Note or Post-Operative
Milestone/Checkpoint Explanation from the ATR templates into the Notes field for
guidance as well.

8) Once complete, select “Save” at the top right portion of the screen to save the treatment.

Figure D2. Tip sheet for revised clinical documentation of treatments into SWOL
AT EMR OPTIMIZATION 47

Figure D3. Screenshot of self-directed learning video demonstrating new workflow for the
clinical documentation of evaluations into SWOL.

Figure D4. Screenshot of self-directed learning video demonstrating the new workflow for the
clinical documentation of treatments into SWOL.
AT EMR OPTIMIZATION 48

Appendix E

Project Application of Program Competencies

Program Competencies

This capstone project focused on the optimization of an EMR which required the use of

many skills revolving around healthcare informatics. Upon reflection, the work encompassing

this project exercised specific skills that fall under each competency for the Master of Science in

Health Care Informatics Program at the University of San Diego.

Health Science Knowledge and Skills

Prior to even pursuing this EMR optimization project, I needed to have a thorough

understanding of health care delivery systems and health care provider roles, specifically in the

profession of athletic training. As with any allied health profession, athletic training is highly

specialized and calls for a specific set of skills needed to deliver care in a fast-paced and

ambiguous environment. As I was also a practicing AT during the project, it was easier to

appreciate the demands of the job and identify measures that would help facilitate job specific

tasks. I also needed to have a background and understanding of medical terminology and the

standards for use of an EMR in healthcare, specifically in athletic training. Understanding

medical terminology, patient evaluation procedures, and EMR build was necessary for me to

fully appreciate the correct data entry methods that would best suit the documentation of

information across various types of provider-patient interactions.

Leadership and Systems Management

Throughout this project, I have recognized that EMR optimization is an immense change

for any department or organization regardless of size. As the project called for the

standardization of documentation workflows, the department would be exposed to a change that

all ATs would be held accountable to regardless of previous documentation behaviors. To

respect this drastic modification in documentation practices, I applied change management

AT EMR OPTIMIZATION 49

concepts related to strategic planning and project management. I used strategies such as end-

user participation in both individual and group settings to create buy-in and potentially

strengthen the success of the project. I was sure to allocate enough time and strategic planning

to include piloting of newly developed workflows to effectively alleviate the stress of

implemented change and allowed for an additional opportunity to identify gaps and other areas

of improvement.

Systems Design and Management

In this capstone project, I included the use of workflow analysis and process mapping

which is a key part of this competency. In doing so, I was able to accomplish the goal of

standardizing documentation workflows utilizing SWOL. However, for this to occur, I first needed

to understand the nature of the interactions between the ATs and SWOL. As a practicing AT, I

felt that I was knowledgeable regarding the specific information needed to document across

each specific patient interaction. This in combination with a gained knowledge of the capabilities

of the EMR empowered me to develop an efficient and streamlined electronic documentation

workflows. I further strengthened these workflows by anticipating failure modes in each process

and addressing them by correcting steps upstream. Although not applied directly in this project,

a failure modes and effects analysis tool as well as root cause analysis tools would be of benefit

to deploy in similar projects in the future.

Data and Knowledge Management

One of my goals for this project was the utilization of data entered into the EMR to guide

clinical decision making for our patient population. I determined that specific variables needed to

be quantified to perform useful analysis included: rate of specific injuries, distribution of specific

injuries across sports and specific sports positions, average number of appointments per day

and distribution of appointments per hour in one day and total cost savings for the provision of

athletic training services to SAs. To obtain these values, I had to be knowledgeable in

appropriate data entry methods within the EMR. After appropriate data collection, I was able to
AT EMR OPTIMIZATION 50

exercise skills in management and manipulation of data using formulation of tables and

application of SQL to a created relational database using Microsoft Excel and Access software.

Quality and Regulatory

To meet this competency, I needed to have extensive knowledge on the management of

the security and privacy of protect health information to manipulate workflows in a safe manner.

I prioritized and considered the preservation of the integrity and security of all information within

the EMR at each step of the processes. I performed research and applied standards for the

optimization of EMRs to frame the modified workflows and modes of data entry. These

standards were gathered from peer-reviewed articles and were crucial in the completion of this

project. By utilizing trusted sources, I was able to apply proven concepts on much larger scales

to our clinic. The primary tool I used to guide the project was the process map. The process

map was utilized to evaluate systems and procedures regarding the interaction between ATs

and the EMR for documentation.

Social Justice and Community Activism

This project meets the competency for social justice and community activism because it

considers the improved quality of care for all SAs at the University of San Diego. My belief was

that by improving our documentation processes, we would be able to improve our care delivery

as a staff for all SAs regardless of age, race, and gender. The improved documentation

standards that I placed may also help in capturing the patient’s entire history in a structured

manner. Having this understanding can help clinicians improve the overall care experience by

considering patient specific information in tailoring their care plans. My future plans is to include

history questions or demographic fields to capture a patient’s gender identity and religious

affiliation if applicable. This information can be used to fully understand a patient’s background

and encourage holistic care.