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SYNCHRONICITY - Implementing Digital Health Records

Published: Synapse Magazine, Fall 2009

When you are sick or in need of hospital care, the last thing on your mind should be memorizing and reciting your medical history. Where your health is concerned, you want to be reassured that all of your doctors and nurses have the information they need at their fingertips. You want to be confident that your caregivers are taking every precaution to ensure the safe delivery of care. The Chester County Hospital has been taking big steps to meet these very reasonable expectations.

In 2001, while many larger institutions were theorizing about the concept, the Hospital was implementing the measures necessary to leave behind the world of paper records. Long before it became an acronym in our current vocabularies, and well before it became a national initiative, the EMR (electronic medical record) was a high priority at The Chester County Hospital.

The wheels of progress began when the Hospital formed a strategic partnership with Malvern-based Siemens Medical to be the first test site for its new clinical information system -- Soarian®.

Ray Hess, Vice President, Information Technology for the Hospital, was there at the beginning. "About a decade ago, we looked closely at where the Hospital was and where we wanted to go in the next millennium. There was recognition in the industry that paper records were going to be a thing of the past." The Hospital had the opportunity to be on the cutting edge of the initiative toward a more secure, efficient, and safer way of caring for patients. He notes, "Our top goal is to assist the clinician in providing consistent, quality care to the patient. Soarian® is transforming how patient care is delivered."

FOR THE RECORD
An EMR must be built from the ground up, with many different components communicating with all the others. The first step was inputting all medical orders and records into the computer and this was launched in May 2008. The second phase is maintaining digital records of bedside care.

Kathy Zopf-Herling, Director of Nursing Informatics, notes, "Most of our inpatient documentation is now converted, with our next phase to include our Intensive Care Unit and the Emergency Department. These areas need the real-time transfer of information between their highly specialized monitoring devices and our clinical documentation forms. As we move forward, we are placing more information at the fingertips of our clinicians."

DOCTORS ORDERS
Pediatrician Karen Pinsky, MD, Chief Medical Information Officer, has been a driving force to move physicians toward Computerized Physician Order Entry (CPOE), which she calls "a powerful tool" for EMR. CPOE allows the doctor to enter medical orders directly into the computer network so the supporting departments, such as the Laboratory or Pharmacy, can fulfill the request with accuracy. She cites the transition as being well received for many reasons, the most important being that it improves patient care and safety. "Compared to the time when doctors and nurses relied on paper and handwritten instructions, there are no longer issues with guessing and legibility. This is a welcome change."

DISCHARGE EDUCATION
Recently, our busy Emergency Department implemented a discharge planning system that provides patients with complete, up-to-date care instructions and printed prescriptions. The system inserts documentation into the patient's electronic medical record of all materials given to them, and automatically faxes the patient's primary physician to alert him or her of the emergency visit. Eventually, this system will go house-wide.

MEDICATION ADMINISTRATION CHECKING
Next on the horizon is an important initiative to implement Bar Coded Medication Administration Checking (MAK), an application that will greatly enhance safe medication delivery and will bolster our EMR with electronic documentation of all medications given to our patients. New computer devices in the patient rooms are being designed to work with the MAK system.

Using the MAK bar coding system, nurses scan the patient's bracelet and the medications before they administer them. MAK checks if the medications are correct for that patient, as well as if it is being given at the right time and the right dose. Additionally, the system alerts the clinician when it is time for the next dose and if the patient has any relevant drug allergies. Zopf-Herling says, "While this new system may not save time in administering medications, the safety measures will give our patients and our nurses peace of mind."

EMR AND YOU
The EMR system may seem superhuman, but it's only as good as the information entered into it -- by the dedicated and diligent efforts of all doctors, nurses and staff. Their efforts are tag-teamed by those of the Health Information Management Department that manage the patients' electronic records in their entirety. Mariann Eavenson, Director of Health Information Management (HIM) Services, notes, "One of the biggest benefits today is the availability of the patient's record to multiple people at the same time, 24-hours-a-day. Doctors have what they need immediately. There is no running to find a patient's chart anymore." HIM Consultant Kim Hagerty, who has helped oversee the movement of paper records to digital records, says, "Our time is better spent. The system has changed the whole landscape of our department. We are now truly managing health information rather than finding it." Both Eavenson and Hagerty have noted significant time reductions since the Hospital's former dependence on paper records. In the old world, the average time in which a physician would complete a patient's chart after discharge was five days. Now, it is within 24 hours. They cite this as "a major accomplishment."

If you need your records quickly for a second opinion or a follow-up visit, they are available. When the Hospital needs to answer correspondence from insurance companies, billing parties, disability agencies, and other physicians, your records are accessible.

The Chester County community can rest assured that their local hospital. The Chester County Hospital -- is not only on par with big-name institutions when it comes to patient-centered technology -- it is well ahead of the curve.

By Jennifer Clemens

Last Updated: 3/15/2010