Quality Assurance in Oncology via the EHR

In order to continue to be in the forefront of the healthcare community, the hospital where I worked moved forward four years ago to implement an electronic medical record (EMR). It was a huge undertaking for this major medical teaching institution. It involved a number of people from every discipline in the hospital. The plan was to begin with nursing documentation and eventually move into physician order entry. I was closely involved in the design, teaching and implementation of these programs. When teaching the classes to the nursing and support staff, needless to say, we came up against some very strong opinions about how difficult it was going to be, how it wouldn’t work, and questions about whether there is a need for this when what we had was “working fine.”

The same feelings were voiced by the physicians when we finally implemented physician order entry (CPOE). Of course, neither came easily nor without growing pains, but both did happen. Fast forward four years. We have worked out kinks, added new forms and documentation, deleted unneeded items and generally become computer-based and have been named the number one wired hospital in the Midwest. What a change we’ve seen both in ability to use the system as well as the acceptance of the electronic chart. I always chuckle a little when, on the rare occasion that the system goes down that I hear nurses and physicians complaining that they actually have to write and use paper charting!

So what have we actually gained? I can best describe that by my recent experiences with other facilities that do not have an electronic medical record. While completing my graduate degree I have been in clinical rotations at several area hospitals, none of which have a complete electronic medical record. Some of the things that have been frustrating for me are the simple day to day things that are different when you still have a paper chart. When I want to look at a chart to review or write progress notes, review orders or find results of tests, the first thing I have to do is locate the chart. How much time is wasted by members of the healthcare team by simply trying to just physically locate a chart? Imagine the time saved from this one simple issue. Then once you do find the chart you spend even more time trying to decipher someone else’s handwriting in the notes or orders. How much safer is it to have physician order entry online to avoid any issues with interpretation of written notes and orders? Another similar issue is that only one person can use the chart at a time.

The electronic medical record allows several people at once to access a patient record and review or document what is needed. Orders not only have become less apt to be misunderstood but the electronic medical record affords practitioners to enter orders into a patient chart from even remote locations. This is a great time saver for physicians, nurses, pharmacy and patients. Safety issues regarding verbal and telephone orders certainly have been affected by this.

Quality assurance tasks certainly have also become easier with the use of the EMR. It’s now much easier to audit a chart for any one of several interventions or issues. If something is documented on the chart, it can be audited in much less time than it takes with a paper chart. This information can be used to change practice or follow up on and resolve patient issues and concerns.

In a 2004 study, both physicians and nurses found the EMR easy to use and were generally satisfied with the impact on their work. Nurses, specifically, reported that they are able to finish their work much faster.

So is it all good? Not necessarily. Every system has its downsides. Currently the system that we use has no ability to generate chemotherapy orders. There are issues with intensive care units that document differently. People can still find ways around required documentation and tasks. My personal observation has been the impact, often negatively, that the electronic medical record has on communication between physicians and nurses. In the past, you had to talk to each other. If a nurse was requesting a new order for something to address a patient need or issue they had to talk to the physician/APN, discuss the issue and need. Now it’s easy to simply page a prescriber with what you need, basic information, and then simply watch the electronic chart for the order to appear. Nurses aren’t learning what or how to communicate with the physicians and physicians aren’t calling to discuss options and issues. This is something that we will need to pay attention to and find ways to address as we move forward.

If you would like to read more about the history of computers in healthcare, a nice overview is given by Berner, Detmer .