Improve Processes With Perioperative EHR

By using electronic records, physicians no longer need to rely on nursing staff to interpret written orders or protocols appropriately.

By using electronic records, physicians no longer need to rely on nursing staff to interpret written orders or protocols appropriately.

By Christy Dempsey, BSN, Terri Budzyna, RN, and Susan Madden, MS

Prior to wide-scale computerization or the implementation of electronic health records (EHR), virtually all clinical documentation was done on paper and errors were rampant. Many times, nurses were so busy that documentation was simply not possible and had to be done later when time was available. This led to missing or erroneous information that could jeopardize patient care.

In addition, charges were not accurately captured or were erroneous. Handoffs between caregivers were often not complete and, as a result, inaccurate or incomplete documentation put the patient at risk.

Similar problems occurred in physicians’ offices. Office records contained all of a patient’s information the clinic practice had amassed during that patient’s history with the physician or clinic. Most of the time, this information was not transmitted to the hospital when the patient was admitted. In addition, during the admission process, this information was requested again by the hospital providers and held in another location. The hospital information was rarely incorporated fully into the clinic office file. This duplication of effort often led to errors and an absence of important data in one or both records.

Even when clinical documentation systems began appearing, rarely did they include the operating room (OR). The OR systems developed for this niche often did not interface with other hospital systems. This caused duplication of effort and a reliance on both paper and electronic records, further increasing the risk for errors or missing information.

Charging in the OR was done on paper and either done during the case, causing some charges to be missed, or done after the case, increasing turnover time. Difficulty remembering exactly what happened during the surgical case often resulted in missing or inaccurate information.

Poor processes and paper-based information systems also impacted patient flow through perioperative services. Finding paperwork such as histories and physicals, lab work, ECGs and medication records that were not on the chart but necessary for the procedure became a problem, leading to delays or cancellations, and increasing the potential for errors or adverse events. There was no way to tell where a patient was in the process at any given time, causing multiple phone calls to locate the patient or the family. Trying to find a bed for a patient who needed to be admitted was also a problem because there was no way to know if the bed was full, empty, available, clean or staffed without making multiple phone calls.

Records Uncover Possible Problems

An enterprisewide information system can include both physician clinic and hospital records, and will follow patients wherever their healthcare is provided. By using electronic records, physicians no longer need to rely on nursing staff to interpret written orders or protocols appropriately, improving the accuracy of the record. Orders for medications are weight-based and applications built into the record check that the order is appropriate for the patient’s weight, allergy status and age.

As the physician places the orders, the application will check for conflicts and warnings that appear if the order falls out of the specific parameters of the medication. This also provides the pharmacist with the ability to verify the order electronically rather than by fax, thus speeding up this process and eliminating many opportunities for error.

Physicians enter, “sign” and “cosign” orders from any computer with Web access. They can see their patient’s chart, review lab work and check messages for issues or information needed in the chart. They can enter notes and place orders for other physician consultations. These orders are time-stamped, and include order set defaults that enable physicians to place orders quickly by checking or unchecking what is appropriate for the patient’s condition at the time.

Improving the communication of medication orders across the continuum of patient care also reduces errors. The EHR assists with medication reconciliation by stepping through the process in the transfer and discharge navigator applications. Each time the patient’s level of care changes, these navigators are used to review home meds, current meds and orders, and discontinue or modify old orders and place new orders along with the transfer or discharge order.

Handoffs from one provider to another are no longer cursory or hampered by missing information. These handoff communications should be documented electronically and be done in a timely manner. Flow sheet rows for vital signs, intake and output, orders, labs and others are presented as links in the handoff. This allows nursing staff to call the handoff nurse while both can open the handoff report and review pertinent details.

Materials management and charge capture is handled electronically. Each procedure has an electronic list of most-commonly used items associated with that procedure so that charging is quick and easy for the nursing staff during the procedure. In addition, this information is fed electronically into the billing system, reducing duplication of effort, and improving the bills’ accuracy.

Improving Patient Flow