The End of the Paper Trail: One Pediatric Hospital's Experience with the Transition to a Fully Electronic Health Record

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Electronic health records (EHR) have been in the national spotlight recently due to the fi nancial incentives included in the American Recovery and Reinvestment Act (ARRA), designed to entice hospitals and physician practices to transition from paper-based record systems to EHRs. However, a recent study found that less than 2% of acute care hospitals have a comprehensive EHR system currently in place, and more than 90% of US hospitals do not even meet the requirement for a basic EHR. Some hospitals, however, have been quick to recognize the benefi ts of EHRs and have already taken steps to prepare for a paperless future.

Anticipating the potential improvements in the delivery of safe and effective patient care, the Children’s Hospital of Pittsburgh (CHP) began the gradual transition to an EHR in 2002. I am a pediatric hospitalist with the Paul C. Gaffney Diagnostic Referral Service (DRS) at CHP and have been able to personally participate in this amazing transition process. The DRS cares for more than 95% of all general pediatric admissions to the hospital. Therefore, our group played an important consultative role in developing and guiding the EHR implementation process.

When I began working at CHP in July 2005, the transition to a completely paperless system was already underway. CHP began to modernize in 2002 with the installation of a computerized provider order entry (CPOE) system and an electronic medication administration record (MAR), which also incorporated lab results and radiologic images. However, documentation was still done by hand. There were two paper charts: one at the bedside for nursing documentation and one in the work area for physician and ancillary staff documentation. At least that is where the charts were supposed to be found! The cry of “Has anyone seen my patient’s chart?” could be heard resonating at each patient care station several times per day. The charts seemed to have the remarkable ability to disappear at the most inopportune times. Even if the chart could be found, there were inevitable battles over access and control among the various medical services charged with providing care to the patient.

The transition to an EHR

CHP began the transition to a truly paperless documentation system by fi rst moving all nursing documentation (ie, signifi cant clinical events, intake and output, vital signs, patient measurements) to the EHR. The next step was requiring the physicians to document their initial history and physical examination notes (H&Ps) in the EHR. This process began with the pediatric residents in November 2007 and then slowly incorporated the pediatric attendings and surgical teams. By January 2009, all H&Ps and daily progress notes were on the EHR, and paper charts could no longer be found on the wards. On May 2, 2009, when CHP moved to its new 1.5 million-square-foot campus, patients and equipment were transported to the new location, but paper chart racks were left behind.

The path to a paperless hospital was far from smooth; our staff had to overcome several signifi cant challenges during the transition to an EHR, not the least of which was providing an adequate number of computers for the providers so they could document electronically. This was made even more diffi cult by the fact that our old hospital building had severe layout and space restrictions. Thankfully, it is no longer an issue at the new location. Currently, CHP has more than 4,000 computers for use by our staff, with more than 400 miles of cabling and nearly 1,800 wireless access points to provide 100% network coverage throughout the hospital. The CHP patient care wards have large nursing and physician work areas with numerous computers available, enabling clinicians to complete their documentation without having to fight over who gets to use the computers. Additionally, several of the workstations are “computers-on-wheels” (COWs)--mobile units that can be easily shifted from one location to another. They can be brought into the work areas if more computers are needed, or wheeled to the patients’ bedsides for medical rounds.

One of the most significant benefits of the EHR for providers has been the dramatic increase in information accessibility. Gone are the days of searching high and low to find a patient’s paper chart. Now, I can access a patient’s chart from any computer in the hospital. Consider that a patient admitted to CHP today will be cared for by an average of 70 clinicians who will view the patient’s EHR more than 500 times over the course of a five-or-six-day hospitalization. Each day, 10 separate authors will enter nearly 20 notes into the patient’s electronic chart. When you consider our entire patient census, that means nearly 45,000 computerized notes are created each month. Given this tremendous demand for access to each patient’s chart, it is not difficult to see the benefits of adopting an EHR.

Going with the fl ow from lab to bedside

CHP has been conducting family-centered rounds (FCRs) since 2008. The EHR plays an integral role during the daily FCR process. During FCRs, team members will need access to the patient’s admissions record, lab results, radiologic findings, and other specific information. Therefore, the team will often bring two or three COWs with them to the patient’s bedside. This point-of-care access to specific and accurate information greatly facilitates the team’s ability to make appropriate patient management decisions. Essentially, ready access to the EHR eliminates the guesswork—Is this truly the most up-to-date information we have for this patient? What is missing from this chart?—associated with paper records. Now, daily patient notes can be created by a team member during FCRs so that accurate assessments and plans are documented. The team member can quickly pull objective data such as vital signs, labs, and radiologic readings directly into the note, which helps to prevent transcription errors.

I am certain that the access to patient information provided by the EHR has improved the fl ow of my work day. I see my patients during FCRs and discuss the plan with the residents and nurses, and with the patient and his or her family. Before our hospital implemented an EHR, I would have to go through the laborious process of fi nding the patient’s chart and then try to write my note quickly (and legibly) before someone else needed the chart. Now, I can return to the comfort of my own offi ce, log on to the EHR, and input my documentation or insert an addendum to the resident note that was already created. Distractions and interruptions are at a minimum in my offi ce, allowing me to spend less time inputting documentation. With our system, I also have the option to securely log on to the EHR from any computer with Internet access anywhere in the world. Therefore, if I have an off-campus meeting, I can enter my daily notes into the system from my laptop or using any computer, wherever I may be.

Patient handoffs and safety

When children are transferred from another institution or come from their primary care physician’s offi ce, all of their paper documentation is placed into a folder to be scanned into CHP’s EHR. Within 24 hours, all of the outside hospital’s documentation can be accessed through CHP’s EHR, and the paper documentation can be appropriately discarded. This means that normal labs and x-rays are not unnecessarily repeated; they are easily found from the prior records, just a mouse click away.

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Another major advantage to using an EHR is that it greatly enhances patient safety. Handwritten orders and documentation can be diffi cult to read correctly, which can lead to signifi cant medical errors. An estimated 44,000-98,000 deaths occur annually due to medical errors. It is suspected that 200,000 adverse drug events each year could be prevented by moving to a CPOE system. Since the implementation of the CPOE system in 2002 at CHP we have seen a 60% decrease in medication safety events. The move to a completely paperless EHR will presumably continue to decrease these preventable adverse events. At CHP, we also electronically scan a barcode on the patients’ ID band and a barcode on the package of any medication that is to be given to the patient. This ensures the administration of the correct drug, at the correct dose, by the correct route, to the correct patient, at the correct time. Additionally, the scanned bar code system enables accurate recording of these parameters automatically into the MAR. CHP has been recognized by healthcare informatics leaders such as HIMSS Analytics (www.himssanalytics.org), The Leapfrog Group (www.leapfroggroup.org), and KLAS research (www.klasresearch.com) for effectively implementing an EHR and improving patient safety.

No time to stop now

It has been a tremendous experience to participate in CHP’s shift to an EHR. While there have been some diffi cult steps during the process, it has overall been a remarkable transition. The information technology group at CHP has been tremendous; it would not have been possible to successfully implement an EHR without the support they have provided to the clinicians and other staff. Due to the EHR, the delivery of patient care has been revolutionized and patient safety has been dramatically improved. It is an exciting time to be in medicine, with technology pointing the way toward an even brighter future.

Kishore Vellody, MD, is an assistant professor of pediatrics at University of Pittsburgh School of Medicine and a member of the Diagnostic Referral Service at Children’s Hospital of Pittsburgh, where he is also the director of the Evening Hospitalist Program.

References

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To Err Is Human: Building a Safer Health System

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