EMR

kshumpertkshumpert
in CDI Talk Archive
Our facility is in the process of implementing our EMR. For those of you that have on in place, I have a few questions. Are you completely an EMR or hybrid. If completely computerized, how long did it take you to roll it out and how was the physician reaction?

Comments

  • dvitalone1dvitalone1
    We are doing the same. Our sister hospital goes live Feb 1st (they are much smaller than us) then we will follow May 1st. We will eventually be totally electronic within 3 mths of initiation. We are going to EPIC. Any suggestion, ideas or comments about EPIC?
  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    We are in the process of goinf to EPIC as well. i am very worried because there has been talk that this position will no longer be needed, that documentation in EPIC will "fix" what we do on it's own. We are a 500 bed teaching hospital. I would love any input.
    Thanks,
    Amy


  • dvitalone1dvitalone1
    edited May 2016
    We are not worried here. There will still need to be education for physicians. They will have choices to select from but will they be the right choices? I am looking forward to EPIC....I will actually be able to read the physician's documentation!




  • david.smithdavid.smith
    edited May 2016
    Yeah, I wouldn't worry too much. The quality of the documentation is
    still going to be dependent upon physician entry of the information, so
    the CDI will still need to review the electronic record to ensure
    complete and accurate documentation. Providers will take short cuts in
    the EHR just as they do in the paper record, so our opportunities will
    still exist (perhaps more so!). E-forms and checkbox templates can
    become tedious and it can be "easier" to select less information in
    order to complete the form or get in the habit of making the same
    selections in similar clinical presentations. I think the EHR possesses
    its own unique documentation challenges and opportunities for
    improvement. It seems like we always hear about the newest technology
    replacing staff, but it is not often the case especially in healthcare
    (i.e. Computer Assisted Coding, Voice Recognition, etc.)


  • robert.hodges2robert.hodges2
    Amy, don't worry about your job. Software never "fixes" anything because it is still people who enter the information. I work where we have a 100% electronic record, and my position started several years after it was implemented. The only advantage you will have now will be able to read the notes from locations other than the floor and you won't have to fight for charts anymore.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    We are a 250 bed teaching hospital and we have been live with EPIC for about 1 year. So much easier to read physicians documentation. Nothing has changed relative to CDI positions. We have new residents rotating in monthly and they still have documentation deficiencies. We still query and educate. One thing we have noticed--they copy and paste progress note data from day to day. This creates a progress note that does not show progress. I think you will find there are additional education opportunities with the ERM rather than less.






  • dvitalone1dvitalone1
    edited May 2016
    How do you query with EPIC?




  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    We use the "sticky note feature" and have gotten good response with it. Our concurrent queries are not part of the MR. We tried the "in-basket feature" and "general e-mail" (labor intensive) and the response rate was poor in comparison to using "sticky notes".






  • kshumpertkshumpert
    edited May 2016
    What product are you using?


    Kathy
    Kathy Shumpert, RN, BSN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Pager 765-604-0424
    Fax 765-453-8152


  • johnsok5johnsok5
    edited May 2016
    We have been live with Epic for around 2 years now. It has not "fixed"
    our documentation problems. If anything, with the ability to copy/paste
    and template in ancillary results we have had more query opportunities
    than ever. We have also not had much luck using the "sticky note"
    function for queries as it does not fit in well with our provider work
    flow. Same with the in basket function.





  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    Sorry about that, It's still EPIC.









  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    Thanks Robert!
    Thanks to everyone for their responses. It is nice to find a place where people understand and are supportive.
    Amy


  • david.smithdavid.smith
    edited May 2016
    Our hospital just instituted a Pressure Ulcer Documentation Form that is completed by nursing on admission. The nurse is responsible for completing form which will pick up the pressure ulcer location, stage, POA. The form will then be co-signed by the physician if in agreement with assessment. There is also an small area above the physician signature for any comments/clarifications that may be needed. I think the key is getting some initial documentation in the record that there is an existing pressure ulcer that the patient came in with so it is clear from the documentation that was POA. I think in terms of ulcer documentation, the POA is fairly straightforward, either the patient has the ulcer or not. I would think the problem could be more on the clinical side, i.e. is the ulcer in fact a pressure ulcer or not.


  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    The nurses in our institution have no trouble understanding POA and they understand the reasoning behind the need for this documentation. There was a large training involving pressure ulcers and documentation a couple of years ago as part of a quality initiative.
    Cindy


  • dbutlerdbutler
    edited May 2016
    At a hospital I moonlight (still want to spend time 'touching' patients and families directly, besides the extra money is pretty good), the admitting nurses are required to document an initial skin assessment (done during their admitting shift) including pictures, measures, descriptions, etc. of any suspected areas. Not sure how the documentation flows from there to the physicians since I moonlight in the ED, but this kind of process I am sure should provide excellent documentation, POA, staging, etc. to work from. This is a small, 40-50 bed hospital.

    Don


  • kmckaigkmckaig
    edited May 2016
    We do not have the nurses document POA. We ask the physicians document POA on wounds. With EMR, nsg takes photos, date them and ID location. These are scanned into the record. We query the doctors to document POA if there is a question.
    Hope this helps!
    Karen


    Karen McKaig, BSN, RN, CCM, CPUR
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org



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