Executive Institute Session
From Paper to Digital: Lessons Learned in Transitioning Trauma Documentation to an Enterprise Electronic Flowsheet
Speaker: Stefanie Fine, MHA-NI, RN, PCCN, LNC
Senior Director of Nursing, Provider, Surveillance, and Ancillary Clinical Documentation Standards at HCA Healthcare
HCA Healthcare, the largest provider of trauma care in the United States, recognized the need to modernize trauma documentation to improve efficiency, compliance, and data integrity across its enterprise. With 108 trauma centers and over 180 hospitals, this initiative aimed to replace paper-based workflows with an electronic flowsheet in Expanse, creating a standardized approach for trauma documentation across the organization.
The strategy involved three pilot implementations designed to validate effectiveness while minimizing disruption to clinical operations. These pilots represented a critical milestone in establishing the enterprise standard for trauma documentation. Strong collaboration across corporate, division, and facility teams enabled success.
Key objectives included defining and standardizing trauma content, ensuring regulatory compliance, and laying the foundation for normalized data to support clinical trials, research, and benchmarking. ROI was realized through cost savings in materials and abstraction resources, automation of trauma registry submissions, and elimination of issues with illegible or missing paper flowsheets. Clinician feedback highlighted improved usability and enhanced visibility of clinical data for tracking and trending.
Key outcomes and benefits:
- Positive clinician feedback on usability and documentation improvements.
- Operational ROI: automated registry data capture, reduced abstraction burden, and financial savings..
- Enhanced data visibility for quality improvement and strategic alignment.
- Instantly normalized data enabling future research, benchmarking, and innovation.
With over 200,000 trauma admits projected for 2025, and 11% of U.S. critical trauma cases treated at HCA centers, this transformation positions HCA to lead in trauma care innovation. This session will share the strategic approach, governance, and lessons learned, offering executives insights into how technology integration and standardization can drive enterprise-level impact, regulatory compliance, and data-driven decision-making.