Although it’s been a long road to EMR adoption with many obstacles in the path, research indicates that the nursing profession as a whole recognizes the benefits of electronic medical records. A University of Pennsylvania study found that nurses using EMRs consistently report better health outcomes for patients in areas like managing chronic illness and avoiding preventable events like pressure ulcers and pneumonia. They credit these improvements to better information and more appropriate screening.
At this stage of the game, the majority of hospitals are dealing with some level of EMR technology. Those who adopted early may now be finding that their clinical systems were installed without the level of expertise available today. Often clinical IT systems were designed or installed without clinical input. So today, hospitals around the country are facing a process known as clinical systems optimization. A key component of optimization is to involve clinicians in these systems from day one.
Because technology is always evolving and healthcare itself is ever-changing, an EMR system is never really finished. Standards of medical practice, diagnostic codes, reimbursement requirements, and documentation standards will continue to change—and health systems will continue to customize their clinical systems to meet their own needs, as they gain a clearer understanding of what works best to promote quality care.
Yet one thing is clear: ongoing updates and design updates to the EMR in general must be driven by clinical processes—which means clinicians, not IT executives, should lead the effort when it comes to system optimization. The EMR should be seen for the clinical tool it is, and not just another technology initiative. IT staff should understand how important it is to involve the end-users, which are doctors and nurses, and to have collaborative discussions as to how the EMR can best enhance workflows and documentation processes.
Nurses are the clinicians who spend the most time interacting with the EMR, documenting vital signs and other patient conditions, physician orders, medication administration, and a host of nursing interventions. Small problems in EMR design can affect dozens of nurses over and over again within a shift, quickly becoming a major drain on efficiency—and this is what the clinical optimization process should address.
While the chief nursing officer is often asked for input on clinical systems, it is also important that optimization is driven by end-user nurses from all areas of the hospital. For example, an ICU nurse will have a different set of expectations from the EMR than a med-surg nurse—the former may focus heavily on detailed documentation, while the latter sees the need for a system that supports discharge instructions and transitions of care. In this way, a clinical system optimization has to take a broad look at the complete clinical environment. As each need is identified, the focus becomes clearer. Optimization must also consider the healthcare organization’s top goals, whether increasing patient satisfaction, meeting specific benchmarks, or decreasing the cost of unnecessary or redundant testing.
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