Providers Orchestrating HIT

[Health IT Social]

The healthcare industry has seen many changes in the management of patient information.  Electronic documentation is progressively replacing paper; handwritten orders are being replaced with computerized provider order entry.  Use of health information technology (HIT) that once was optional has now become essential to streamline care, access up-to-date evidence-based care recommendations, make patient data more accessible through centralization, and report patient care results to regulatory agencies.

This intensified attention may have some providers feeling as if the electronic record is being inflicted on them, rather than seeing it as a tool to assist them in their practices.  Legitimate concerns are raised that the computer will be an obstacle between provider and patient, and that ordering and documenting in the computer will be slow and cumbersome.  Health care providers do not have time for awkward systems. In a hospital, health care providers and clinical staff are required to use the electronic medical record (EMR) provided. While no EMR can meet every need, it is possible to increase efficiency and intuitiveness of the tools available.

The first step toward effective electronic ordering and documentation is user buy in.  If those who will use the process are not involved in its development, it is unlikely to meet the users’ needs.  Providers know their workflow; provider input is necessary to translate that workflow to the electronic world. 

Process Clean Up

It must be noted that translating dysfunctional processes into the electronic world does not improve them. If anything, the computer will turn a bright light and magnifying glass on process breakdowns. A handwritten progress note consisting only of “patient says she’s feeling better” is glaringly inadequate when viewed in the EMR. A discharge instruction to “continue home meds” cannot compare to electronic medication reconciliation between the patient’s home medication list and inpatient medications.

The onus of improving content does not fall only on the shoulders of providers. Without timely and accurate documentation from nursing, lab, diagnostic imaging, care managers, and therapies, providers have little material with which to work. Creating a comprehensive, quality patient record requires conscientious effort from all disciplines. While the maxim ‘garbage in, garbage out’ may be harsh, it is important that process weaknesses and breakdowns be identified and rectified before automation.

Conclusion

Expansion of HIT is inevitable. The difficult transition from traditional paper patient records can be improved by the involvement of providers at all stages in the development of electronic orders and documentation. At the same time, it is the responsibility of all disciplines to improve the quality of content entered into the EMR – higher quality in, higher quality out. By working together, the healthcare team can create an EMR that meets the needs of all involved.

 

Holly A. Hoskinson is a Clinical Informatics Coordinator at Island Hospital