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From Paperwork To Patient Care The shift from paper to electronic record
keeping means more time for caregivers to concentrate on their
essential mission of caring for patients.
As published in Provider Magazine – March 2001 – Lynn
Wagner
Three Rivers Nursing and Rehabilitation Center in
Cincinnati, Ohio is on the cutting edge of medical record keeping.
The 169-bed skilled nursing facility with 220 employees is one in a
small universe of health and long term care providers that have
eliminated paper records and replaced them with a wireless,
electronic medical record (EMR) system.
The system is the culmination of hundreds of hours of
planning and customization to meet the documentation and reporting
needs of the facility. Today, nursing staff no longer sit behind a
desk at the nursing station for hours each shift to do paperwork and
charting. Instead, nurses do all charting on mobile,
battery-operated computers that roll through each of the facility’s
three wings on medical carts. Each wing also has a wall-mounted
touch screen computer, where certified nurse assistants can
instantly call up a care plan to see what each patient requires.
The shift to automated medical records began with a
search for ways to operate more efficiently, says Rod McKinley,
administrator of the facility. “We looked at our professional staff
and the time they spent charting and sitting behind a desk and were
hearing from them that they were not doing what they were trained
for,” says McKinley. The nursing staff maintained thick patient
charts that were “falling apart” from use, and nurses had to make
duplicate entries to fulfill all required documentation. “Everything
was time-consuming, outdated, labor-intensive and taking time away
from direct care,” McKinley says.
Finding the Right System
Three Rivers reviewed many paperless charting systems
before making its selection. Pamela Putnam, the facility’s director
of nursing, spent more that 500 hours customizing the software to
achieve both the greatest ease of use by the nursing staff and
compliance with federal, state and accreditation requirements. The
resulting EMR system allows medical record entries to be made in a
matter of minutes using a touch screen computer screen.
Detailed patient information on
everything from assessments and vital signs to medication and
therapies is entered only once and automatically populates the area
of a medical record – including the minimum data set – where it is
required. The facility can call up a variety of records and reports
within seconds when patients are being discharged or transferred to
the hospital or when physicians require the latest information on a
patient’s condition and vital signs. Authorized staff from the
facility can also access the password-protected system by dialing in
from a remote location. The system also tracks quality indicators to
aid clinical management and targeted quality improvement efforts,
Putnam says.
Selection of the wireless system also involved review
of several proposals. Once the system was chosen, antennas were
installed on each of the three wings and hard wired to a server in
the business office. Installation of the equipment was piggybacked
with an already planned renovation project. The wireless equipment
makes it possible for information from the mobile units to transmit
to the antennas, which send the data to the server.
Three Rivers spent nearly a year
getting all existing paper records transferred to the electronic
medium. The system went live in November 1999, and the facility has
now had all of its records in electronic format for more than a
year.
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