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A New Picture of Patient Care
The handwritten medical chart is going digital on the East Baltimore campus.

blank Kim Antinone
Kimberly Coursen-Antinone says the electronic sharing of psych records across the health system is bound to improve continuity of care for patients.

Nurses have long been the gatekeepers of the patient medical chart, the metal folder stacked with papers that chronicles a patient’s hospital stay. It’s no wonder, then, that when Hopkins Hospital was looking to convert the myriad documents in the chart to an electronic version, nurses would use their intimate knowledge of the patient record to help get it done.

The challenge was daunting: to round up hundreds of forms, many of which had been tailored to specific clinical departments and disciplines, and to synthesize them into a set of core electronic documents that could be used anywhere in the hospital. They also needed to identify thousands of uniform terms that caregivers could select to describe patient conditions within those digital forms. Which words might a caregiver use to classify a patient’s breathing activity, mental state or stool color?

This painstaking work was key to the creation of a computerized system scheduled to launch in the Department of Psychiatry and Behavioral Sciences beginning Sept. 21, followed by Neurosciences and Neurosurgery on Oct. 4, with a broader rollout starting in early 2010. The system lets caregivers from across Hopkins log in and get quickly up to speed on a patient’s care, rather than piecing it together by flipping through paper.

"We’re going from a unit or departmental patient record to a patient-centric record," says Elizabeth Taffe, project lead for clinical documentation in Nursing.

Although just a few departments will switch to the system this fall, any clinician on campus who sees patients treated in those areas could be affected, says Peter Greene, chief medical information officer for Hopkins Medicine. "If those patients get sent down to physical therapy or radiology, or if a consultant sees the patient, people on those outside services have to be prepared to gather data from this system."

Today, patient information is scattered across multiple locations, forcing users to shift between sections of the paper chart and different digital systems. But with the transition of clinical documents to computers, Hopkins will take a major step towards a comprehensive electronic health record system. The documents will be housed in the hospital’s Sunrise Electronic Health Record, the same system where clinicians enter orders, view radiology and lab results and look up medication administration records.

While physicians, Social Work, Nutrition and other disciplines all contributed to the documentation project, nurses from multiple departments performed much of the detail-laden work of determining what information to capture digitally and how it could be presented electronically to improve patient care. "Everybody was willing to take off their departmental hats, listen to the discussions and really come to agreement—what are we going to chart here," says Taffe.

The process took thousands of hours, spanning more than a year, and required close work with Johns Hopkins Medicine Center for Information Services.

Kimberly Coursen-Antinone, clinical informatics project manager in Psychiatry and a leader of the implementation team, says the new system will help clinicians to more quickly spot patterns in a patient’s care. One interface will consolidate all information into a grid summarizing a person’s health problems, visit history, lab results and other clinical data.

"Even with something like vital signs, before you had to kind of look back through the paper chart," she says. In the Sunrise system, "you can look at the whole picture."

Another benefit is that once a piece of information is entered, the Sunrise system automatically pulls that data into other forms that ask for that same data.

"Currently, the patient is asked at least five different times about their past medical history, allergies and what meds they are on at home," Taffe says. "Now, once the data is collected and entered, nobody needs to ask that question again."

Overall documentation may shrink. Psychiatry, for example, pared 143 paper forms to 43 electronic documents by eliminating redundancy and changing work processes.

The new system could also help avert transcription errors associated with using pen and paper and improve communication between caregivers at transfers of patient care.

But such enhancements will also demand new ways of working.

The electronic system encourages users to enter information as it’s collected. Knowing that caregivers have different work styles, project leaders want to provide as many options as possible. So in addition to hallway workstations, computers-on-wheels and laptops, Psychiatry is piloting voice-recognition software and electronic tablets that convert handwriting to type.

"We’re hoping that this flexibility, in the end, will make more people on the units comfortable using the new system," says Dennis Barton, clinical director for Psychiatry and an implementation team leader. "That’s the major hurdle we have to get past."

– Jamie Manfuso and Stephanie Shapiro



Johns Hopkins Medicine

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