Federal policy makers have set 2014 as the target year for all Americans to have an electronic health record. While researchers claim that health information technology (IT) holds great promise to improve the quality and efficiency of healthcare delivery, the path to effecting the transition to computer-based documentation systems is fraught with obstacles. In addition to large initial capital investments for upgraded hardware and software, hospitals face other barriers to IT adoption. The challenges experienced by hospitals making this change include steep learning curves, workflow disruptions, and time delays.
The biggest mistake you can make is to have physicians feel that you’re forcing something down their throats that slows them down.
—Richard Todd, MD
Advancements and Glitches
A 2005 American Hospital Association (AHA) survey of 900 community hospitals found a wide range of IT usage. Some hospitals have completed installation of bar coding for medication management, while a small minority are using advanced computerized physician order entry (CPOE) systems.1 Typical of many hospitals in the AHA survey, Abbott Northwestern Hospital in Minneapolis chose an incremental IT implementation approach.
Academic hospitalist Debra L. Burgy, MD, is the lead physician in Abbott Northwestern General Medicine Associates Group, affiliated with the internal medicine program at the University of Minnesota (Minneapolis), where she is also adjunct assistant professor of medicine. Hers was the first group of physicians to go live with the hospital’s electronic documentation system 16 months ago, in July of 2005.
“We went up on July 1 because we thought it might be an advantage to have a long weekend with a lower census,” she recalls. As it turned out, her group of academic hospitalists was caught short-staffed on the holiday weekend, having to adjust to their new IT roles, take care of patients, and orient the brand-new interns.
“It was kind of a sad weekend for me,” she remarks wryly.
Of the launch in July 2005, Dr. Burgy observes that the learning curve “was longer than I expected, but once you achieve it and you’re adept at most of the functions I do find [electronic documentation] better overall in many ways.”
One advantage: As an academic hospitalist, she consults with her residents and emergency department admitting physicians in real time by pulling up patients’ charts from any location.
Dr. Burgy and her colleagues still find the time required to enter the narrative part of the patient’s history of present illness difficult, as well as the discharge notes. Another bug: The system is designed to prompt the physician to complete medication reconciliation (Medication Administration Record, or MAR) at admission, transfer, and discharge. Because the medications are not organized in alphabetical order or side by side, however, the logistics of reconciling more than a few medications can be frustrating.
“Most of us end up printing out the current MAR, which seems to defeat the purpose of the computerized record,” says Dr. Burgy.
A Staged Approach
According to Mary A. Dallas, MD, chief medical information officer for Presbyterian Healthcare Services (PHS), an integrated healthcare delivery network in Albuquerque, N.M., PHS launched CPOE in the main hospital’s inpatient services area as the final step in the pharmacy automation process designed to improve patient safety and prevent medication errors.
Five years ago, the main hospital began the process of developing a closed-loop pharmacy order system. Now, with this system in place, medication orders go directly from the physician’s fingertips to a pharmacy work queue. The verified drug order is then messaged to the pharmacy robot for packaging. On the floor, nurses’ hand-held devices flash a message that the drug order is ready. Upon delivery to the floor, a nurse scans the bar code on the packaged medication, matches it to the patient’s bracelet bar code, and scans his or her badge before administering the medication. This verifies the 5 “Rs” of medication safety: right medication, right dose, right route, right patient, and right time, as well as concurrently creating the electronic MAR.