2.50
Hdl Handle:
http://hdl.handle.net/10755/162905
Type:
Presentation
Title:
An Electronic Emergency Department Medical record Sounds Like Alphabet Soup
Abstract:
An Electronic Emergency Department Medical record Sounds Like Alphabet Soup
Conference Sponsor:Emergency Nurses Association
Conference Year:2006
Author:Haines, Diana, RN, MSN, CEN
P.I. Institution Name:Lehigh Valley Hospital - Muhlenberg
Title:T-System Analyst
Contact Address:2545 Schoenersville Rd., Bethlehem, PA, 18017, USA
Contact Telephone:(484) 884-2465
Co-Authors:Diana Haines, RN, MSN, CEN; Charlotte Buckenmyer, RN, MS, CEN; Christina Lewis, RN, BSN, MPH; Courtney B. Vose, RN, MSN, CRNP
Clinical Topic: Electronic documentation was visualized as a means to improve the current performance improvement process by providing the capability to immediately review any case and provide real-time follow-up if necessary with staff at this tertiary care Magnet facility located in Pennsylvania on three campuses each with its own emergency department (ED). The major goal of automated documentation was to improve patient safety by providing staff simultaneous access to patient records. The electronic document would provide a clinical record that was legible, end the paper shuffle, and eliminate the missing paper charts. Ultimately, electronic documentation would improve efficiency by providing a means of quick concise documentation. The goal of this project was to facilitate a smooth transition from a paper to an electronic emergency department medical record in the three emergency departments. Implementation: In May 2004, a multidisciplinary steering committee, spearheaded by ED leadership and information systems specialists, was formed that included ED nursing staff and all ancillary departments involved with patient care documentation. Components to be implemented included the electronic documentation system , Computerized Assisted Physician Order Entry (CAPOE), and Electronic Medication Administration Record (EMAR); all of which interfaced with the network information system. The implementation process involved three phases (each with its own educational component). Phase I included an overall introduction and use of a paper-based template. In Phase II, CAPOE and EMAR were implemented following with the implementation of the electronic documentation system in Phase III. Nursing committee members participated in integration and functional testing, which prepared them to be expert users who provided continual staff support and feedback through all phases of implementation. Education preceded each implementation phase, which included 40 providers, 20 float staff, 85 ED staff for the first site, 40 ED staff for the second site, and 160 ED staff for the third site. Overall, 15 ED staff members and 12 providers served as expert users. The implementation began in December 2004 and was completed in June 2005. Outcomes: Implementation, evaluation, and process improvement were completed at one site before moving to the next hospital. Processes were progressively refined based upon feedback from staff and expert-users following each site implementation. Staff concerns were continually identified and addressed throughout implementation. Providing a new means of documentation initially caused the nursing staff to change their practice to adapt to the computer system, resulting in an increased patient length of stay. Staff was encouraged not to change their practice to adapt to the system, but to instead allow the system to adapt to their practice. Staff also had to be reminded not to share computers with other staff since documents were electronically signed under user-specific numbers. To protect patient confidentiality, the importance of locking computer terminals was reinforced. Additionally, documentation policies and guidelines were developed and reference manuals were printed and placed in each emergency department. Recommendations: It is recommended that the number of internal changes (that affect staff) be limited during a monumental process change such as this. It is equally important to recognize that individuals integrate change at different rates. Ongoing support from expert users and leadership, along with staff involvement in both evaluation and process improvement is critical to the successful transition to using electronic medical records in the emergency department.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleAn Electronic Emergency Department Medical record Sounds Like Alphabet Soupen_GB
dc.identifier.urihttp://hdl.handle.net/10755/162905-
dc.description.abstract<table><tr><td colspan="2" class="item-title">An Electronic Emergency Department Medical record Sounds Like Alphabet Soup</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2006</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Haines, Diana, RN, MSN, CEN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Lehigh Valley Hospital - Muhlenberg</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">T-System Analyst</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">2545 Schoenersville Rd., Bethlehem, PA, 18017, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">(484) 884-2465</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">Diana.Haines@lvh.com</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Diana Haines, RN, MSN, CEN; Charlotte Buckenmyer, RN, MS, CEN; Christina Lewis, RN, BSN, MPH; Courtney B. Vose, RN, MSN, CRNP</td></tr><tr><td colspan="2" class="item-abstract">Clinical Topic: Electronic documentation was visualized as a means to improve the current performance improvement process by providing the capability to immediately review any case and provide real-time follow-up if necessary with staff at this tertiary care Magnet facility located in Pennsylvania on three campuses each with its own emergency department (ED). The major goal of automated documentation was to improve patient safety by providing staff simultaneous access to patient records. The electronic document would provide a clinical record that was legible, end the paper shuffle, and eliminate the missing paper charts. Ultimately, electronic documentation would improve efficiency by providing a means of quick concise documentation. The goal of this project was to facilitate a smooth transition from a paper to an electronic emergency department medical record in the three emergency departments. Implementation: In May 2004, a multidisciplinary steering committee, spearheaded by ED leadership and information systems specialists, was formed that included ED nursing staff and all ancillary departments involved with patient care documentation. Components to be implemented included the electronic documentation system , Computerized Assisted Physician Order Entry (CAPOE), and Electronic Medication Administration Record (EMAR); all of which interfaced with the network information system. The implementation process involved three phases (each with its own educational component). Phase I included an overall introduction and use of a paper-based template. In Phase II, CAPOE and EMAR were implemented following with the implementation of the electronic documentation system in Phase III. Nursing committee members participated in integration and functional testing, which prepared them to be expert users who provided continual staff support and feedback through all phases of implementation. Education preceded each implementation phase, which included 40 providers, 20 float staff, 85 ED staff for the first site, 40 ED staff for the second site, and 160 ED staff for the third site. Overall, 15 ED staff members and 12 providers served as expert users. The implementation began in December 2004 and was completed in June 2005. Outcomes: Implementation, evaluation, and process improvement were completed at one site before moving to the next hospital. Processes were progressively refined based upon feedback from staff and expert-users following each site implementation. Staff concerns were continually identified and addressed throughout implementation. Providing a new means of documentation initially caused the nursing staff to change their practice to adapt to the computer system, resulting in an increased patient length of stay. Staff was encouraged not to change their practice to adapt to the system, but to instead allow the system to adapt to their practice. Staff also had to be reminded not to share computers with other staff since documents were electronically signed under user-specific numbers. To protect patient confidentiality, the importance of locking computer terminals was reinforced. Additionally, documentation policies and guidelines were developed and reference manuals were printed and placed in each emergency department. Recommendations: It is recommended that the number of internal changes (that affect staff) be limited during a monumental process change such as this. It is equally important to recognize that individuals integrate change at different rates. Ongoing support from expert users and leadership, along with staff involvement in both evaluation and process improvement is critical to the successful transition to using electronic medical records in the emergency department.</td></tr></table>en_GB
dc.date.available2011-10-27T10:36:09Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:36:09Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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