Another Children's First: Fully Integrated EMR
The Children's Hospital is the first, free-standing pediatric hospital in the nation to fully implement an integrated Electronic Medical Record (EMR) system. This achievement enables physicians and other caregivers to access patient records electronically through secure technology whether they are at Children's, their office, an outside clinic or other location.
"It's a very exciting achievement; we went into the implementation of EMR on a fairly aggressive schedule to meet the needs of the campus transition," said David Kaplan, MD, professor of pediatrics, University of Colorado School of Medicine, and TCH's Chief Medical Information Officer. "There was pressure to get the record implemented for both the outpatient clinics and all the inpatient units, and ensure we have a system that is stable and efficient before we move."
A major benefit EMR offers to care providers is having all patient data available in one place, including past medical history, lab results, consults from sub-specialists, images and reports.
"For the first time, we have everything we need available at our fingertips," Dr. Kaplan noted. "Documentation is much more complete than ever before. It's more organized; notes are not missing as sometimes would be the case with the paper record."
Hospital Fellows, who are often off-campus during their research training time, also benefit from ready access to information pertinent to patient care.
Another EMR function will enhance Children's ability to monitor suspected abuse cases. A novel, model way of charting abuse reports, the system uses a SCAN (Suspected Child Abuse and Neglect) encounter.
"Children's is the first pediatric hospital to integrate an EMR that includes child abuse services," explained Andrew Sirotnak, MD, Department Head, Child Abuse & Neglect and Director, Kempe Child Protection Team. "We can effectively report out how many children are reported as suspected child abuse cases, for what reason or diagnosis, and from what unit or area."
During the reporting, a hyperlink flags the chart as a previous reported case so any user can access this data anywhere in the network of care. In addition, the CPT clinic can upload sensitive photos to a secure server.
"Clinical social work staff and our Child Protection Team have worked collaboratively with the EREX group to make this happen, and as team leader and department head, I couldn't be more proud of that fact," said Dr. Sirotnak.
Changing to Accommodate EMR's Benefits
Implementation has been a complicated undertaking with significant changes in workflow. "It required staff on all levels to reassess the collection and capture of clinic and administrative information. It also required that we reexamine policies and procedures," explained Dr. Kaplan.
"It took a fair amount of time to adapt to the new flow and technology," noted Michael R. Narkewicz, MD, Hewit Andrews Chair in Pediatric Liver Disease, Professor of Pediatrics, and President of The Children's Hospital Medical Board. "We are still in a learning phase of how best to integrate EMR's strengths and challenges into clinical practice."
Challenges were identified in intensive care areas, where compiling patients' orders and inputting data is considered to be more involved in a time-sensitive environment.
"Everybody has faced changes, in particular, the physicians, who over the years have honed their workflow to improve efficiency and patient care in specific areas," added Dr. Kaplan. "By redefining our workflow, we were on the frontline."
Physicians interviewed noted that they are spending more time documenting in EMR, resulting in a reduction in the number of patients seen.
"There certainly are opportunities to improve in this area," said Dr. Narkewicz. "The major challenge is how to optimize EMR to benefit the greatest number of patients and providers. To be most useful, we will all need to adhere to certain ways of using the system to get the most from this powerful tool."
Another obstacle is how to keep users informed about EMR to optimize efficiency and patient care.
"We have users who rely on EMR two-four times a year, and very facile experienced users, who see untapped power and potential and can't wait for the next improvement," said Dr. Narkewicz.
For his part, Dr. Kaplan sees unlimited potential and reduced stress levels for EMR users. "Three years from now there will be less training required, and the process will be more comfortable for both physicians, other care providers and patients," he noted.
Eyeing What's Next
To keep up-to-speed, Dr. Narkewicz and his team meets on a regular basis with EMR support staff to discuss workflows, processes and issues impacting efficiency, patient safety and workflow.
"We are piloting systems such as medication verification to allow us to develop the best process before we institute a change across the entire institution," he explained. "We have reexamined the flow of patients in the outpatient clinic, and modified and adapted roles for providers to try and leverage the EMR."
While frustrated by bumps in the EMR road, Dr. Narkewicz acknowledges that the hospital is in the infancy of EMR implementation. "There are still significant challenges of adapting this system to a diverse large pediatric hospital with a strong clinical and research mission," he said.
Dr. Kaplan adds, "As pioneers in this implementation, we must remember that this process is ongoing, and will be for a long time. We understand we will need fine-tuning and product upgrades that we cannot install now because of the transition."
Joan Bothner, MD, agrees. "It is true that we are in the early stages of the EMR implementation. Although fully implemented, there will be an ongoing and continuous process of re-evaluation and optimization with the goals of enhanced efficiency and multidisciplinary collaboration leading to best outcomes," she explained. "We now have the opportunity to begin to fully understand and take advantage of the vast benefits of an electronic health record."
Dr. Kaplan applauds physicians for their support and patience during the complex implementation which began nearly three years ago. "They have worked hard to adjust, and they have invested a considerable amount of time assisting with the system's build for sub-specialties," he said.
After the move, upgrades are expected to further improve ordering and communication with community partners such as referring physicians. In addition, training techniques will be reviewed and enhanced for rotating trainees.
"It's a work in process, not just a simple installation," Dr. Kaplan emphasized. "What is really exciting is that we have many modalities in place that are not in use at other pediatric institutions, and now, they are calling us with questions about our process!"
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