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Transcribed notes are going the way of the dinosaur at Glancy Rehab Center of Duluth, GA. The rehab facility, which is part of the Lawrenceville, GA-based Gwinnett Hospital System, has plunged ahead with a paperless documentation system dubbed QUEST, which stands for Quality, Uniformity, Efficiency, Safety through Technology.
"We began this project to improve safety for our patients, improve timely access to information, and to improve patient, associate, and physician satisfaction," says Jo Driscoll, RN, senior project manager
of Gwinnett Hospital System.
For instance, an electronic physician order entry and medical documentation system will eliminate some of the more common medical errors caused by incorrect interpretation of clinician handwriting, Driscoll says.
"We want to improve patient care, and we can do it through technology," she says.
Driscoll predicts that many hospitals across the United States will move in the direction of electronic medical records in the next decade.
Change to electronic system takes lots of work
At Glancy Rehab Center, documentation traditionally has been entirely handwritten, and in the inpatient setting there have not even been transcribed notes and reports, says Katrina Stone, MA, education coordinator/post acute services for Glancy's inpatient program. So the change to an electronic system has been a lot of work, especially in the beginning, Stone says.
The first phase of the hospital system’s and rehab center’s switch to electronic documentation was launched in March. By August, the system had about 50% of its data loaded in the computer system, Driscoll says.
In two subsequent phases, the transfer will include having all physician order entries made electronically, and finally, having all therapists document electronically, Driscoll says.
Here’s how the hospital system and rehab center have developed and implemented the switch to a paperless documentation system:
• Building the electronic infrastructure.
The hospital system purchased Sunrise Clinical Manager (SCM) software from Eclipsys Corp. of Boca Raton, FL, in which to build a database to execute the system, Driscoll says.
Developing an electronic data system requires input from all areas of the health care organization, including Stone as a rehab representative, because there are so many special needs for each clinical area.
"In March, 18 team members were chosen from the various departments throughout the hospital to represent their areas in building the system," Driscoll says. "We also have a steering committee to oversee the implementation of the software."
After setting expectations and providing team-building sessions, an Eclipsys consultant was brought in for training. Then team members were given assignments to collect the data needed to build the system for their areas.
The first assignment had team members return to their departments to create their own departmental team. Stone pulled together representatives from each rehab discipline and spoke to them about the rehab facility’s current documentation process and how it might be made more efficient through an electronic system.
Order results will be available on-line
• Phase one: Orders and results.
In the first phase, which will be implemented in late summer of 2003, the move to an electronic documentation system involves loading data into the software program so there will be order management, and results of those orders will be available on-line, Driscoll says.
All orders will be entered into the SCM system, and the requisition will be sent electronically to the ancillary departments. The results of those orders, along with transcription, will flow into SCM from the ancillary systems. This will make the information readily available to physicians who need to access the data, Driscoll explains.
If a physician at the rehab unit wants to check on a patient from a remote location, the physician can look at the file via the internet, provided he or she has the correct access and security rights to view that patient file, Driscoll says.
Developing common terminology
• Adjust rehab culture and terminology.
"We had to go back into our departments and come up with common language across rehab and identify what we call something in rehab vs. what we call the same thing in acute care and sports medicine," Stone says. "We’ve created common terms to place in the database."
This is a complex task, because the terminology that will be used by all rehab staff needs to make sense to everyone. Some staff will have to get used to using a new word or description for an activity. Plus, the new terminology will need to be used by physicians, who traditionally have been able to write whatever they please on their orders, leaving other staff to decipher their meaning, Stone says.
The ultimate goal is for all rehab staffers to be on one page in how they understand the documentation instructions and terminology.
"We’re trying to build Gwinnett’s culture into the framework of an electronic clinical system
so that it makes sense to the staff," Stone says. "We’re using our rehab terminology, acronyms and policies and procedures, so that our staff — when they are oriented to this — will say, This is logical and I can follow it.’"
Obviously there will be some major changes. For instance, paper process flowcharts that now run up to four pages in length will be reduced with an electronic medical record, Stone adds.
"We’ll do significant simplification as well as enhance patient care time," Stone says.
• Phase two: Physician orders.
An Information Physicians Advisory Council meets monthly to discuss any electronic documentation issue that requires physician input, Stone says.
"The physician coordinator facilitates this meeting — and we’re not leaving them out of the loop," Stone says. "Physicians are an integral part of planning."
Physician buy-in is crucial because the second phase will require them to enter all orders electronically, eliminating the paper order forms. The second phase also will have nurse practitioners and physician assistants keying in orders electronically as appropriate for the physicians they represent.
"In rehab, the unit clerks, staff who take verbal orders over the phone, and the physicians will input the orders electronically," Stone says. "All caregivers will be able to read those orders, and other people can screen them as appropriate for the patient’s care."
Plus, when clinicians order a lab test or therapy intervention, they will easily be able to see the results. On the electronic screen, a physician who is reviewing a patient’s chart will see green or red flags indicating a result or that a document is available in the file, Stone says.
The color of the flag will indicate a normal order or result vs. an out-of-range result or stat order.
Once physicians have fully implemented the new electronic documentation system, the rehab facility and hospital will have greater efficiency and more accurate data, leading to increased patient safety, Driscoll says.
Currently, when a physician orders a medication, it has to go on paper and be sent through the pneumatic tube to the pharmacy and be verified, passing through several hands along the way. This creates a greater potential for misinterpretation and error, Driscoll says.
"With the electronic physician order entry system, the physician will enter the medication order into SCM and it will go directly to the pharmacy, reducing handling and lag time, which will reduce errors," Driscoll adds.
• Phase three: Therapist documentation.
When the final phase is implemented, all clinical and support staff will be using electronic charts and notes, including rehab notes, nursing notes, and flow sheets, Driscoll says.
"When we have all three phases completed, the only thing in the paper chart will be consent forms that patients sign, along with other documents that are not included in the SCM system," Driscoll says. "Our goal is to eventually have an electronic medical record for each patient in our system."
Therapists will be able to pull up all charts on the computer, do their charting in the electronic format, review other therapy charts, and easily understand all of the information, Stone says.
"The system allows a facility to establish charting standards with certain rehab treatments, choices, and responses set up in text boxes and pull-down lists to assist the clinician with their charting," Driscoll says. "It will make it more efficient and safer for patients."
Since the electronic format will include information cues and shortcuts, there will not be a great need for staff to type in text. The system will utilize touch-screen technology that keeps someone moving quickly through the required computer fields, Stone says.
All electronic charts will require passwords and identity log-in so that the patient information meets the new privacy regulations and cannot be accessed by unauthorized personnel, Driscoll says.Need More Information?
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