Making the case for electronic health records

By

Pam Brainerd

Carla Brown

Kelly Bustos

Jonathan Butler

Camille Herrmann

2005: George Bush calls for Electronic Medical Records for every American.

2009: Barak Obama states every American should have an EMR by 2014.

The thought was that EMR’s would improve healthcare, cut costs, and promote efficiency, revolutionizing the industry.

What is an EMR?

“An electronic medical record (EMR) is a digital version of the traditional

paper-based medical record for an individual”

(http://whatis.techtarget.com/definitions/electronic-medical-record.emr.html)

EMR’s can be the electronic record at one facility, or can be shared by facilities.

Some EMR’s are owned by the individual, so no matter where he or she goes, the record goes too.

EMR’s can include all of the health information pertaining to a person or a visit. This can include vital signs, age, height, weight, lab results, testing results, MD Orders, and pharmacological information.

Why the big push for electronic records? What’s wrong with the paper version?

-paper records no longer meet the needs of the industryor it’s consumers.

-only one person can access paper records at any given time.-paper records cannot include diagnostic studies.

Positives of EMR’s:

-can integrate patient information into one record-can improve the quality of health information-contains cost-decreases wait time-increases productivity-improves patient satisfaction-multiple disciplines can accessthe same information at the same time.

With paper records no longer satisfying the needs, and the push by politiciansto create an electronic record for every person, funding has been dispersed, vendors have created programs, and more and more facilities are making thetransition from paper to electronic records.

To emphasize the difference that an electronic record can make for a patient,we will follow an individual in an emergency room visit in two scenarios:

1. paper-based emergency room visit2. electronic records-based emergency room visit

Emergency Room Visit Using non-EMR

Emergency Room Visit Using non-EMR

Patient comes to ER with complaints of:• Nausea• Vomiting• Headache • Diarrhea

Emergency Room Visit Using non-EMROnce the patient is called to the triage area, the nurse will complete:

•Patients demographic info

•Vital signs

•Allergies

•Home medication list

•Advance directive/emergency contact info

•Patient’s signs and symptoms

All information will be charted on a paper flow sheet and passed on to the physician to see the patient in the exam room

Emergency Room Visit Using non-EMR

• Once all information has been entered and the physician has seen the patient, the physician will then make a diagnosis and make orders for labs and meds to have the nurse carry out.

Emergency room visit using non EMR

•After Physician and RN make initial

assessments the Physician will now write

orders.

•The RN must interpret the hand written

order by the physicians and any other

RNs involved in the care.

•The assessments and orders must be

legible

Emergency room visit using non EMR

• Physician will hand write orders for each department in which tests are needed.

• RN will then call each department informing of new orders and new patient.

• Laboratory

• Imaging

• Pharmacy

• Bed openings if necessary.

• Dietary if admitted

Emergency room visit using non EMR

• Laboratory

• Phlebotomist will hand write labels or

type with patients name and room

number.

• Phlebotomist will have RN sign that blood

draw occurred and receive a copy.

• CMP, CBC, PT, PTT, vial will be drawn

with type and screen and copy of order.

Emergency room visit using non EMR

• Imaging

• X-ray, CT, Ultrasound,

MRI have been notified by

RN as needed per order.

• BUN, Creatinine clearance entered by RN in nursing notes per order.

• IV site, size and location

per order and put in note.

Emergency visit using non EMR

• Pharmacy

• Home medications listed on

medication sheet.

• Allergies are listed.

• Pharmacist is given patients weight

for correct dosing.

• Dosage, route and time per order

called or faxed to pharmacy.

Emergency room visit using non EMR

• Nursing Orders are placed in nursing

notes per physicians orders.

• Foley Catheter and NG tube placement

entered into nursing notes.

• I&O entered in nursing notes and written

on I&O sheet.

• D5NS @125cc/hour stared per MD order

and written in nursing notes.

From the patients point of view:

• Time from triage to testing was two hours.

• Time from testing to MD telling diagnosis: 1 ½ hr.

• Time from diagnosis to interventions: one hour.

Emergency room visit using non EMR

• Bed Placement.

• RN notifies supervisor of need

for bed.

• Acuity level, Isolation status and

if male or female is all written

down in nursing notes as being

performed per MD orders.

Emergency visit using non EMR

• Dietary

• Nurse instructs food service if patient is admitted. Pt is NPO; no tray.

• Any food allergies.

• Religious dietary food restrictions if any.

• What type of diet, regular, mechanical soft, pureed, thickened or non thickened liquids.

• If tray needs to be sent up. All information is written in nurses notes and on dietary request.

Jones, J. (2012). Personal Communication.

Emergency room visit using non EMR

• Nurse will complete

assessment and information

she/he gathered from patient.

• MD will finish any information

or further orders in chart.

• All information is handwritten

in chart.

• Time from interventions to

admission: two hours.

Patient transferred to inpatient bed.

Total patient care time in Emergency Room: 6 ½ hours.

Now we follow this patient in a facility that uses Electronic Records.

Emergency room visit using EMR

Emergency room visit using EMR

Patient presents to ER with the following complaints:

• Nausea

• Vomiting

• Headache

• Diarrhea

Emergency room visit using EMR

In triage, the RN would document in EHR:

• Patient’s demographic information

• Allergies

• Home medication list

• Advance directive/emergency contact information

• Patient’s sign and symptoms

• Patient identification wristband printed

Emergency room visit using EMR

• After RN completes the triage assessment, patient will be taken to the examination room where MD will visualize the patient’s EMR

Emergency room visit using EMR

• MD would examine the patient and enter the appropriate Computerized Physician Order Entry (CPOE).

Emergency room visit using EMR

Orders would be generated in eachdepartment’s task list such as

• Laboratory• Imaging• Pharmacy• Nursing• Bed placement (if necessary)• Dietary (if admitted)

Emergency room visit using EMR

Laboratory

• CBC, CMP, PT, PTT, type & screen. Labels printed automatically in lab.

• Phlebotomist notified immediately to draw

specimen via pager.

Emergency room visit using EMR

Imaging

• X-ray, Ultrasound, CT, MRI notified depending on MD orders. Mandatory input fields for IV size & location, allergy information, lab values for BUN, Creatinine

clearance.

Emergency room visit using EMR

Pharmacy

• Home medications listed on the medication reconciliation screen.

• Allergies shown

• Safe dosage according to weight assured by pharmacist.

• Timed doses of medication prompted by EHR.

Emergency room visit using EMR

Nursing Orders

• Nursing orders appear on the task list

as they are entered by the MD.

• Strict I &O

• Foley catheter

• Insert NG tube

• NPO except medications

• Start D5NS @ 125cc/hr

From the Patient’s Point of View:

• Time from triage to testing: 45 minutes

• Time from testing to MD telling diagnosis: 30 minutes.

• Time from Diagnosis to Interventions: 20 minutes.

Emergency room visit using EMR

Bed Placement

• Notifies nursing supervisor of need for bed.

• Acuity level

• Isolation status

• Male or female patient

Emergency room visit using EMR

Dietary

• Instructs food services to not send a tray (if admitted)

• Food allergies and sensitivities displayed

• Religious dietary restrictions observed

• Food consistency orders depending upon swallowing ability followed.

Emergency room visit using EMR

MD would complete patient’s H&P on his or desk while

orders are being carried.

Time from interventions to admission: 1 hour, making total time in the ER 2 hours and 35 minutes.

Conclusion

It is evident that electronic records improve many aspects of patient care.

1. The patient is seen and examined more quickly.

2. Diagnostic studies are completed in a timely manner.

3. Results are uploaded, and diagnosis made.

Conclusion

The patient in this scenario experienced relief much more quickly in the electronic version of the visit than in the paper version.

Conclusion

The plan mandated by politicians for every American to have an EMR by 2014 is a lofty goal, but very much worth the effort.

• EMR’s will improve patient satisfaction

• EMR’s will cut costs

• EMR’s will improve work flow and efficiency

Conclusion

• If you were the patient in this scenario, which visit would you have preferred to encounter? The paper visit? Or the Electronic Record Visit?

References

Bernd, D. L., Fine, P. S. (2012). Electronic Medical Records: A Path Forward. Frontiers of Health Service

Management, 28 (1), 3-13.

Eisenberg, S. (2010). Electronic Medical Records-Life in the Paperless World. ONS Connect, 8-11.

http://whatis.techtarget.com/definitions/electronic-medical-record-erm.html.

http://www.emrandhipaa.com/emr-and-hipaa/2009/1/14/obama-wants-full-ehr-by-2014.

Nicholson, S. (2011). Electronic Medical Records and You. Risk Management, 46-49.