Our hospital purchased an Electronic Health Record (EHR) two years ago. We hired a consulting firm to rapidly roll out the software and, within two months, the hospital went live on the new EHR. We didn’t have much training and many clinicians were left guessing where to type in notes or enter vitals. An incident occurred where laboratory data was displayed with the oldest value at the top instead of reverse chronological order. A patient did not receive a statin because the most recent cholesterol test result was listed at the bottom of the screen. The physician only reviewed the results that were at the top of the screen.
An EHR can help promote patient safety, but its success is implementation-dependent. Hospital leaders conduct an assessment of goals for technical readiness. Along with the vendor, the hospital outlines an implementation plan. The plan is implemented, a group of hospital staff members are trained, and they go through a mock “go-live” and pilot test. An actual “go-live” goes without a hitch, perhaps a few minor glitches, but essentially, the EHR is implemented.
The SAFER Guides are self-assessment booklets designed to help healthcare organizations optimize the safety and safe use of electronic health records (EHRs). Each begins with a checklist that can be used by a multidisciplinary team for assessing their organization’s level of implementation of each recommended practice.
The Office of the National Coordinator for Health Information Technology (ONC) has taken several steps to increase reporting to PSOs and facilitate providers’ ability to collect data and solve problems. Among other actions, ONC has established prizes for application development and has proposed placing Common Formats (the national standard taxonomy and electronic format for reporting to PSOs) into meaningful use criteria.
As of late, I’ve heard the buzzword “meaningful use” thrown around liberally when it comes to discussions about electronic health records. The whole point of medical records is to document patients’ care and have all the pertinent information in one place for the multidisciplinary teams to review.