Your EHR Isn’t Just for Storing Health Records.

An Electronic Health Record is computer software used to capture, store, and share patient data in a structured way. An EHR inrervention is able to share medical information among all the authorized parties involved in the patient’s care: clinicians, labs, pharmacies, emergency facilities, nursing homes, state registries, and patients themselves.

The first EHR prototype called a Problem-Oriented Medical Record appeared 50 years ago. It consisted of a database of a patient’s complete clinical history, a problem list with the patient’s medical complaints, initial plan of care in which a doctor decides what to do about the problem, daily progress notes, and a discharge summary that tells about the fullest resolution of a problem emphasizing the remaining concerns.

Patient handoff tool

The increasing fragmentation of health care has the unintended consequence of more care transitions. Transitions of patient care between providers occur frequently and require providers to transmit critical clinical information. If information is omitted or misunderstood, there may be serious clinical consequences . Several studies have shown that handoffs are often variable and represent a major gap in safe patient care.

In addition to care transitions into and out of the hospital (extra-hospital handoffs), hospital care itself has become increasingly fragmented due to the increase in number of resident handoffs secondary to duty-hour regulations and the adoption of the shift-work type systems utilized by hospitalists. In-hospital handoffs are common in hospitals and represent a vulnerable time during patient care. For example, hospitalized patients are often passed between doctors an average of 15 times during a single five-day hospitalization. Poor handoffs lead to uncertainty during clinical decision-making, which then leads to potential harm (near misses) and inefficient work in both resident and hospitalist service changes. Handoffs between levels of care, such as critical care to floor, or operating room to post-anesthesia care unit (PACU), also represent potential for information loss and communication failure. 

Using handoff tool for right patient identification

Patient safety is crucial for the delivery of effective, high-quality healthcare and is defined by the World Alliance for Patient Safety of WHO as ‘the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum’.To illustrate the impact of patient safety on healthcare quality, the incidence of adverse events is commonly cited. Following the definition of Brennan et al, adverse events are injuries that are caused by medical conduct resulting in prolonged hospitalisation and/or disability at the time of discharge.

The Joint Commission reported that poor communication is a contributing factor in more than 60% of all hospital adverse events they reviewed.Poor communication is found in many different healthcare settings and is especially prominent in patient hand-offs and settings where fast and effective management is indispensable. Such settings include the perioperative period,5 the intensive care unit ICUand the emergency department.The components and processes of communications are complex and prone to misunderstanding. To overcome these barriers, communication strategies are desirable, which take little time and effort to complete, deliver comprehensive information efficiently, encourage interprofessional collaboration and limit the probability of error.-R,

Implementing a perioperative handoff tool to improve postprocedural patient transfers.

Handoffs in the perioperative setting–the period during which the patient leaves the operating room (OR) and arrives at the postanesthesia care unit (PACU) or intensive care unit (ICU)–have received little attention. A perioperative handoff tool consisting of an OR-to-ICU/PACU protocol and checklists incorporates a defined process, a specified team structure, a procedure for technology transfer, and clearly defined information elements to share. The tool could be applied to any periprocedural setting in which a patient is physically transferred from the procedural location (with the associated procedural team) to a postprocedural care unit with a different care team.

Tool shared to handoff patient

The surgical services shared governance staff leadership council at NCH hasused the SHARED model to create a communication tool for handoffs as part of itseffort to improve interdepartmental communication (form, p 16).“It was helpful for us to have our shared governance council involved in creationof this tool because the staff perceived it as an extension of their own ideas ratherthan just another form to fill out,” says NCH’s director of surgical services, Judith

Knupp, RN, MA.The entire council had input into the tool, and input was gathered from otherstaff as well, notes Jill Moscato, RN, APN, OR advanced practice nurse.Important to acceptance, along with staff input and buy-in, was having nurses

and other staff members explain the tool to each other, rather than just putting theform on the chart, says Knupp.Filling out the SHARED tool is not the same as documenting in a chart. “TheSHARED report is simply a work sheet to help the staff organize their report to othercaregivers and not a permanent part of the patient’s record,” she emphasizes. The report is discarded at the end of the patient’s surgical experience.

Improving continuity of patient care through the use of a universal handoff tool

Background: During patient handoff, critical information is communicated from one provider to another. There have been multiple attempts by institutions across the U.S. to make this process as streamlined as possible. Within our institution, there is currently no universal protocol for patient sign-out to nursing staff for post-operative management. One study estimated that the typical teaching hospital has 4,000 patient handoffs every day or 1.6 million per year. Substandard handoffs are estimated to play a role in 80% of serious preventable adverse events.

Methods: Prior to instituting use of a “patient handoff” template in our hospital’s EMR in the form of an SBAR note, an anonymous 10 question multiple choice questionnaire was distributed to the nursing staff of the post anesthesia care unit (PACU) and surgical intensive care unit (SICU). This questionnaire assesses where they feel the level of continuity of care and quality of patient handoffs post-operatively currently stand. 6 months after instituting the universal handoff template, the same questionnaire was distributed to assess for any subjective improvement in patient care post-operatively secondary to better continuity of care and clarity of post-operative management goals.

Best practice patient handoff tool

Communication is a key aspect of care in the health care setting. Handoffcommunication occurs between medical provider’s numerous times a day. Eachpatient handoff performed has the potential for ineffective communication, leading topoor patient outcomes. The Joint Commission has recognized handoff communication asone of the main causes of sentinel events, or unexpected events that results in patientharm or death, in the health care setting (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2012).

The Joint Commissions National Patient SafetyGoal requires “a standardized approach” for provider handoffs. The introduction of achecklist or handoff tool has been shown to significantly reduce morbidity and mortalityas a result of ineffective handoff (Potestio, Mottla, Kelley, & DeGroot, 2015).This project focused on the utilization of a standardized handoff tool postoperatively in patients undergoing cardiac surgery being directly admitted to the cardiovascular intensive care unit (CVICU). A handoff tool was created from evidencebased practice and presented to Certified Registered Nurse Anesthetists (CRNAs) at a medical facility in central Mississippi. CRNA’s were asked to assess the tool by fillingout a survey on the effectiveness of the tool. They also evaluated the potential need forthis policy in their facility and daily practice.

Which activity or intervention should be avoided when implementing an ehr system?

Physicians will count clicks and do not want to be stopped during order entry unless it is necessary. An overuse of alerts will cause alert fatigue.

Which activity or intervention should be avoided when implementing an ehr system

Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers. These features address traditional well-known requirements for documentation principles while supporting expansive new technologies. Use of these features without appropriate management and guidelines, however, may create information integrity concerns such as invalid auto-population of data fields and manufactured documentation aimed to enhance expected reimbursement. Processes must be in place to ensure the documentation for the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely.

There are a number of existing rules and regulations on documentation principles and guidelines that primarily address documentation authorship principles, auditing, and forms development in a paper health record. New guidelines are being sought by the healthcare industry that ensure and preserve documentation integrity in an age of electronic exchange and changes in the legal evidentiary requirements for electronic business and health records.

EHR wil help improve patient assessment intervention

Healthcare professionals worldwide have transitioned from handwritten documentation to electronic reporting processes. In North America, over half of office-based practices and hospitals use some form of electronic health record (EHR) documentation. Clinical electronic documentation is referred to in this review as “the creation of a digital record detailing a medical treatment, medical trial or clinical test. Compared with conventional paper documentation, EHRs produce clear, legible data that lends itself well to the support of patient care, communication among health professionals, quality assurance, and providing source information for coding for administrative databases used in research. Although EHR documentation has existed since the 1960s, a review of the medical literature reveals that the quality and usability of EHR documentation is generally poor.

Several problems with EHR documentation have been identified. These include structural problems in which documentation quality suffers if the EHR system does not have built-in logic prohibiting the user from continuing onto the next section of documentation if the previous section has not been completed. Similarly, free-text fields, as opposed to point-and-click radio button documentation, have demonstrated increases in error.Resistance to EHR adoption further inhibits the standardization of documentation and can also impact data quality and usability.