It was October 1996 when I first started working in a hospital IT department. At that time, we were involved in the software implementation of administrative workflows. The target was to eliminate the traditional appointment book in the ambulatory area and the register books in the emergency department (ED).
Nowadays it is difficult to find this kind of book in hospitals but they are still used in some small clinics.
The hospital managed the traditional paper documentation using many resources. There was a complex process for asking, moving and returning the dossiers (and sometimes some were lost in the process). It was necessary for staff to move the dossiers around the hospital and a huge space was required to store the thousands of medical records.
What was happening in the emergency department (ED) at this time?
The patients arrived at the ED and the doctors attended them without asking for the medical record. Why did they act this way? Because time and resources made it unavoidable:
- In the ED, in most instances, a patient cannot be left waiting so finding the existing medical record was not an option except in some complex cases where previous information was key for certain decisions.
- The workflow of the transportation of medical records had a delay of 24 hours and the process for immediate transportation was only for emergencies.
The lack of clinical information at the point-of-care was normal at that time, we had fewer variables to make decisions but we attended patients as organisations without IT support.
The introduction of the electronic medical record (EMR) solved the problem of lack of clinical information and improved the clinical process in terms of time spent with the patient and access to the tests needed for diagnostics.
But is this all EMR can do?
A short discussion with a medical director shows the roadmap for the EMR. The target is clear: safety, quality and efficiency. Improving these values needs a set of initiatives in the implementation of the electronic medical record in the ED.
There are some basic workflows that must be implemented, as these are the foundations of the platform and without them, it is difficult to improve. The next five points describe these functionalities.
Foundations of the platform:
I. Unified order platform. All the clinical orders used by a clinician during patient care must able to be managed easily, quickly and intelligently in a unique page screen. This has to include laboratory, radiology, pharmacy and other clinical tests as well as clinical consultations, appointments and other procedures.
II. Access to clinical documentation without barriers. All the clinical documentation must be available to the physicians and nurses regardless of whether the record comes from primary care, ICU, ambulatory visits, surgery area or other areas. It is fundamental not to have islands of information and, today, this is quite common.
III. Integration of diagnostic tests in the EMR. Each test done in the care process has to be integrated with the EMR and this means an online flow of orders and results of the laboratory, radiology, electrocardiogram and other common ED tests. The integration will make it possible to implement alerts that are triggered by important results.
IV. Closed loop medication process. Medication can be a risk for the patient in some cases, due to allergies, interactions between different drugs or errors in the dose administered. Implementing algorithms in the EMR for avoiding these threats adds a level of additional safety to the care process.
V. Different workflows for different pathologies. The admission process must implement a patient triage starting different workflows for different pathologies or types of patients, trying to do the best for each case and introducing clinical pathways and best practices.
The real complexity in IT projects is in defining the order catalogues, making agreements between the different departments, defining the algorithms for alerts, allergies, and interactions and creating the standard pathway.
Let’s look at the relationship between the previous five conditions and safety, quality and efficiency. The cause–effect relationship is easy to establish:
A. The unified order platform saves time on ordering and detects duplicity or previous similar tests that the patient has undergone. Through a unified EMR, a hospital or a healthcare system creates a single source of correct information for each patient’s health record. For that reason, it adds efficiency to the process, optimises the care given and improves patient experience. Providers communicate patient care decisions more efficiently and effectively. Nurses and other ancillary caregivers are immediately made aware of patient care decisions. And pharmacists receive clear and precise care decision information. Multiple providers can work simultaneously on the same record, even if they are based in different locations. These efficiencies eliminate time wasting, duplicative processes.
B. More clinical information at the point-of-care improves efficiency as it results in less time for diagnosis but it also increases safety, thanks to the availability of the clinical information from previous contact with the patient.
C. Real-time clinical decision support systems are poor if they do not have online results of laboratory, vitals and other tests. Good algorithms use clinical data to implement the rules. In this case, the clinical decision support system (CDSS) is adding safety and quality in the care process. In addition, the clinical decision support system helps reduce patient safety risks and financial impact due to over-testing, over-prescribing, prescribing expensive drugs when there are low-cost alternatives, and referring without proper work-up.
D. Nowadays, everybody knows that one important cause of clinical errors is the medication administered to patients in hospitals. There are multiple benefits of automating the medication integration process:
- Improved safety through reduction of human error such as errors caused by illegibility of written notes, transcription errors, errors in the Five Rights process (the right patient, the right drug, the right dose, the right route, and the right time).
- Automation of positive patient identification (PPID).
- Verification of the Five Rights.
- Automation of charge capture and improved charging accuracy.
- Improved compliance with standards for patient identification and documentation.
- Consistent messaging at the point-of-care.
- Power at the point-of-care.
Having the closed loop medication process is a key for adding safety checkpoints for physicians. It means they can focus all their effort on applying their knowledge instead of carrying out certain checks that the IT solution can do for them.
E. The best way to provide quality of care for every patient and disease is by following best practices or standard verified pathways. Clinical pathways provide a standard of care for patients with specific conditions. With this, standard ordering and documentation guidelines are followed and included within decision support to allow clinicians to easily determine best practice and provide consistent patient care. For example, the ED department pathways should be aligned with clinical pathways such as asthma, head injury, pain, fractured neck of femur, CAP and other complex pathways. This is without any doubt a way of increasing quality of care.
The results will come in the universal index such as readmissions, mortality, and length of stay. All of which will improve in global numbers but calculating these for each pathology will open a way for us to study continuous improvement in ED based on the more common pathologies treated.