Kendall Cortelyou-Ward

EHR Implementation in a New Clinic: A Case Study of Clinician Perceptions

Driven by the Health Information Technology for Economic and Clinical Health (HITECH) Act large numbers of physicians and hospitals are now implementing electronic health records (EHR) with the general expectation that such systems will improve the quality, safety and efficiency of health care services. Studies of conversions from paper to electronic records paint a mixed picture with healthcare providers pleased with some aspects of their EHRs but dissatisfied with others. These prior studies focused on conversions from paper to electronic records. Many provider impressions, therefore, may have been influenced by reactions to the process of being required to change well established patterns. In order to help separate such reactions from true evaluations of the efficacy of the EHR, we decided to survey the providers in a new health center. To insure that the information gathered was not merely anecdotal, we used a well-established format starting with a semi-structured interview which facilitates analysis and recognition of major themes. We included questions around several important areas including workflow, communication, patient satisfaction, productivity, documentation, and quality of care. Ten main themes emerged: impeding patient flow, hindering communication in office, improving communication after the visit, improving tracking of patient care, spending less time with patients, requiring more training, wanting more features, diminishing productivity, appreciating benefits of templates, and enhancing internal communication. The need for better training appeared to be of especially high importance as it impacted several of the other themes. We believe that our study helps validate the similar concerns expressed in studies of transitions from paper to electronic record systems. Our method may be generally useful to other clinics because it facilitates timely recognition of themes, both positive and negative, that clinicians and clinic managers would want to know at an early stage. Prompt knowledge of such developing themes may help to accentuate the positive aspects of the EHR and to prevent negative themes from developing into serious problems that might be considered serious unintended consequences of EHR usage.

Use of electronic health record documentation by healthcare workers in an acute care hospital system.

EXECUTIVE SUMMARY Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this information is used for patient care, and the amount of time clinicians perceive they review and document information in the EHR. A survey administered at a large, multisite healthcare system was used to gather this information. Findings show that diagnostic results and physician documents are viewed more often than documentation by nurses and ancillary caregivers. Most clinicians use the information in the EHR to understand the patients overall condition, make clinical decisions, and communicate with other caregivers. The majority of respondents reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with much of this time spent completing detailed forms seldom viewed by others. Various flow sheets and forms within the EHR are rarely viewed. Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation. New forms and input fields should be added sparingly and in collaboration with informatics staff and clinical team members to determine the most useful information when developing documentation systems.

Mitigating Error Vulnerability at the Transition of Care through the Use of Health IT Applications

Adverse drug events are largely considered to be errors in which the severity of effects could be lessened or even prevented through more effective medication reconciliation practices. Transitions of care, particularly at the time of discharge from the hospital, represent a time of heightened error vulnerability that contributes to medication discrepancy occurrences. The observed vulnerability can be attributed to communication and care continuity gaps across health care settings and can often lead to preventable errors. Health IT tools developed through research can identify factors which increase the risk of medication discrepancies. Additionally, the implementations of optimized clinical workflow processes to form effective transitions of care are approaches to decreasing medication discrepancies which may lead to adverse drug events. While federal policies and certifying organizations have implemented quality initiatives to increase focus on medication reconciliation practices in the hospital and primary care settings, the same practices must be implemented after a patient is discharged to their homes or another health care facility in order to mitigate error vulnerabilities that occur at the transition of care. This paper provides an overview of health IT system capabilities and their applications within and across health care delivery settings to facilitate care coordination to ensure continuity of care.

Utilizing Telemedicine Techniques to Confront Rural Mental Health Care Challenges: The Progression Towards a Technological Health Ecosystem

Due to the unique population characteristics of Rural America, the diagnosis and treatment of medical conditions is a challenge. This is especially true when specialists are needed, in particular for mental health care including psychiatry. Provision of care often falls to primary care providers, who may fail to recognize symptoms or misdiagnose a condition. In addition, a stigma is often attached to mental health issues and precludes many people from seeking treatment, particularly due to embarrassment and perceived confidentiality issues. This paper will describe the rural population and mental health issues faced by patients and providers. Challenges will be explored from a systems theory viewpoint, as well as from community development perspectives. Solutions will be offered ranging from the broad theoretical perspective including policy options, and specific solutions for practitioners in various settings. Of particular focus is telemedicine in the form of telepsychiatry. This option is mentioned throughout this paper in terms of current usage in specific settings as well as provider and patient acceptance of the technology.

The American Recovery and Reinvestment Act: lessons learned from physicians who have gone electronic.

The recently passed American Recovery and Reinvestment Act (the Act) is a landmark piece of legislation that will shape health care informatics in the United States for the foreseeable future. The Act provides financial incentives to hospitals and physicians who upgrade their medical record systems by implementing electronic versions. This article defines health care informatics, outlines the provisions of the Act and associated incentives that are available to hospitals and physicians, discusses the advantages and barriers related to upgrading to an electronic medical records system that have been identified in the literature, and details several case studies where small physician group practices put electronic medical records systems into operation. The analysis of these cases shows that the challenges faced by the physicians and practice administrators reinforce the key challenges identified in the literature. Given these seemingly common impediments, suggestions for overcoming such challenges are summarized. These key lessons should be of interest to any practice looking to upgrade their medical records system.

The laboratory workforce shortage: a managerial perspective.

Most clinical laboratories in the nation report severe difficulties in recruitment and retention of most types of personnel. Other important factors impacting this problem include work complexities, increased automation, and a graying workforce. As a further challenge, institutional needs for clinical laboratory personnel are expected to grow significantly in the next decade. This article examines the current situation of the clinical laboratory workforce. It analyzes the different types of personnel; the managerial, supervision, and line positions that are key for different types of laboratories; the job outlook and recent projections for different types of staff; and the current issues, trends, and challenges of the laboratory workforce. Laboratory managers need to take action with strategies suggested for overcoming these challenges. Most importantly, they need to become transformational leaders by developing effective staffing models, fostering healthy and productive work environments, and creating value with a strategic management culture and implementation of knowledge management.

The effect of work environment on intent to leave the nursing profession: a case study of bedside registered nurses in rural Florida

The purpose of this research was to explore the effect work environment has on the intent to leave the profession for rural hospital bedside registered nurses (RNs). Subscales of autonomy, control over the practice setting, nurse–physician relationship and organizational support were incorporated into the analysis to determine which aspects of work environment directly affect the intent to leave the profession. An explanatory cross-sectional survey was distributed to 259 direct care bedside RNs employed at a rural system-affiliated hospital in Central Florida between February 2007 and June 2007. Anonymity was assured. A questionnaire containing demographic questions, the Nursing Work Index-Revised and Blaus intent to leave scale was distributed to all direct care nurses. A 32.8% response rate was achieved for a total of 85 complete and usable surveys. Data analysis shows that the work environment in general is negatively related to intent to leave. In addition, each of the four subscales was also negatively related to the intent to leave the profession. The results of this study support several recommendations for practice and education, including the promotion of professional practice environments, fostering inter-departmental relationships, and increasing the managerial training of RN managers.

The use of governance tools in promotion of health care information technology adoption by physicians.

Electronic health records are important technology for health care with promises of streamlining and improving care. However, physicians have been slow to adopt the technology usually because of financial constraints. Third-party payers, including Medicare and Medicaid, are coming forward with solutions and funding. While payers have the most to gain in terms of cost savings, they have been slow to provide a solution to the financial dilemmas posed by the new technology. This article details some governance tools that are frequently used to alleviate the financial concerns. Grants, loans, and tax expenditures are some of the options available to physicians to purchase electronic health records and other types of health care information technology.

Electronic health record project initiation and early planning in a community health center.

Community health centers exist to help their constituents become proactive in addressing their own health care needs and to improve the overall well-being of the community. However, they pose a different set of challenges when implementing an electronic health record system. This article applies 2 project management principles, initiation and early planning, to the electronic health record implementation in a community health center. Issues such as planning, financial considerations, and quality improvement are discussed.

Hospital in-house laboratories: Examining the external environment

As hospitals fight for their portion of reimbursed health care expenditures, it will become increasingly necessary to investigate alternative funding mechanisms. In-house laboratories, which have likely been seen in the past as pure cost centers, can be repositioned to provide additional revenue to hospitals. This opportunity for in-house laboratories to be remade into profit centers is predicated upon a thorough understanding of the environmental factors affecting hospital laboratories. This article examines 4 distinct environmental factors: demographic and socioeconomic trends, reimbursement and financing, government policy, and clinical events. Each of these external environmental factors provides 2 broad sources of interest to hospitals and their in-house laboratory components: opportunities on which to capitalize and hazards against which to defend.