EMR 'one size does not fit all': Nurses' and midwives' opinions about using electronic medical records

The primary objective of this study is to analyze the different patterns of electronic medical record (EMR) documentation corresponding to updating assessment results and how these patterns would be different inside and outside the patient room in a medical intensive care unit in terms of average process time. In this study, the real-time measurement system data was used to analyze ICU nurses’ workflow related to the EMR documentation. After that, multiple hierarchical task analysis charts were developed to find different EMR documentation patterns for assessment results. The results revealed that the patterns of EMR documentation were significantly different in terms of average process time. The findings from this study might identify the areas of EMR where improvements can be made by preventing disruptions, incompleteness, and optimizing the EMR process efficiency in a medical ICU.

The impact of electronic medical record systems on outpatient workflows: A longitudinal evaluation of its workflow effects

The Electronic Medical Record (EMR) incorporates computerised provider order entry systems which allow clinicians to order diagnostic tests electronically, thus eliminating the need for cumbersome handwritten orders. In many situations the EMR relies on a manual transition of information across systems (e.g., integration with the Laboratory Information System). This study, based in a laboratory setting requiring such a transition across systems, aimed to compare the data entry time (from when a specimen arrives in the Central Specimen Reception [CSR] area of the laboratory, to when it is forwarded on for processing), along with a laboratory turnaround time (TAT) (from the time a specimen is received to the time a verified result is issued) for paper and EMR orders, for two high volume tests, across six hospitals. Results showed that the median data entry time for all hospitals combined, was three minutes shorter for EMR entered orders than paper orders. This difference was consistent and significant for Electrolytes, Urea, Creatinine (EUC) and Automated Differential (including full blood count) tests in 2010 and 2011. These decreases contributed to significantly lower median Laboratory TATs for EMR orders (for EUC tests the difference in medians was 12 minutes in 2010 and six minutes in 2011; for Automated Differential tests, the difference was four minutes in 2010 and two minutes in 2011).

Technological developments have an impact on developments in the world of health, especially information technology in hospitals. The use of EMR makes medical records more orderly and improves health services that are faster, more precise, valuable and accountable. User usage and satisfaction will influence individual impact. Methods: An analysis of the relationship between EMR documentation and nurse satisfaction is needed. This study used a cross-sectional, The sampling technique in this research used purposive sampling correlational design with a sample of 80 patient at RSUD Dr. Soetomo. Research data was collected through questionnaires from the EMR documentation performance variables and nurse satisfaction. The results of the validity test of the EMR Documentation Performance instrument obtained a Parson correlation value in the range 0.590-0.926 > r table 0.514 and the results of the reliability test in this research showed a Cronbach's Alpha value of 0.966 so it is reliable. results of the validity and reliability of the patient satisfaction instrument Cronbach α reliability coefficient was high, ranging from 0.900 to 0.940. Research data was processed using the Spearmen rho test with a p value <0.05. Results: The results of the study showed that EMR documentation performance was related to patient satisfaction (0.009). Discussion: Good electronic medical record documentation performance can increase patient satisfaction.

125 Background: Improving incidence of code status documentation in the electronic medical record (EMR) has been suggested a better guidance for clinical care compared with a traditional advance directive. We have previously reported that in the absence of a template in the EMR, code status documentation was 36% and inconsistent in patients with advanced cancer. Utilizing a different cohort of patients with metastatic pancreatic cancer, we examined the prevalence of EMR code status documentation. Methods: A retrospective analysis in patients with analytic metastatic pancreatic cancer (2008-2014) was conducted at a single, academic medical center. The primary objective was to determine prevalence of code status documentation in the EMR. Secondary objectives were to determine documentation author, location in the EMR, and time from documentation until death. Patients were identified from a tumor registry and code status documentation was identified in the scanned media, demographics tab, problem list, or using key search terms in the EMR. Results: 169 patients with stage IV pancreatic cancer were identified. Seventy-five percent (n = 127) had a code status documented. Of those with documented code status, 44.9% (n = 57) were full code/full care, 22.0% (n = 28) were DNR/comfort care, 18.9% (n = 24) were DNR/full care, 13.4% (n = 17) were DNR/not specified, and 0.8% (n = 1) was limited DNR/full code. EMR locations for code status documentation included: 71.7% (n = 91) discharge summary, 10.2% (n = 13) inpatient encounter, 10.2% (n = 13) history & physical, 6.3% (n = 8) media tab, 0.8% (n = 1) telephone encounter, and 0.8% (n = 1) admission note. Code status documentation was completed by hospitalists (42.5%, n = 54), medicine residents (21.3%, n = 27), and primary oncologists (4.7%, n = 6). Mean difference for date of code status documentation and death was 67±145 d. Conclusions: Code status documentation was higher for patients with metastatic pancreatic cancer compared to patients with advanced cancer from a previous study at our institution. Research is needed to determine if full code/full care is a default selection or a true representation of a patient’s wishes. Future efforts need to consider a standardized location for code status documentation in the EMR.

The adoption of electronic medical records (EMRs) in ambulatory settings has been widely recommended. It is hoped that EMRs will improve care; however, little is known about the effect of EMR use on care quality in this setting. This study compares EMR versus paper medical record documentation of basic health history and preventive service indicators in 47 community-based practices. Differences in practice-level documentation rates between practices that did and did not use an EMR were examined using the Kruskal-Wallis nonparametric test and robust regression, adjusting for practice-level covariates. Frequency of documentation of health history and preventive service indicator items were similar in the 2 groups of practices. Although EMRs provide the capacity for more robust record keeping, the community-based practices here do not use EMRs to their full capacity. EMR usage does not guarantee more systematic record keeping and thus may not lead to improved quality in the community practice setting.

Implementation of electronic medical record (EMR) systems within developing contexts as part of efforts to monitor and facilitate the attainment of health-related aims has been on the increase. However, these efforts have been concentrated on urban hospitals. Recent findings showed that development processes of EMR systems are associated with various discrepancies between protocols and work practices. These discrepancies were mainly caused by factors including high workload, lack of medical resources, misunderstanding of the protocols by health workers, and client/patient practices. The present review focused on the effects of EMRs on patient care work, and on appropriate EMR designs principles and strategies to ameliorate these systems.

Introduction The challenge with burn documentation needs in electronic medical record systems is recognized and often limited in the foundation of commercial electronic systems. In October 2016, our institution transitioned to a new all-inclusive electronic medical record. The transition to this new Electronic Medical Record (EMR) afforded us the opportunity to develop and build burn specific documentation needs in the new EMR system. In this paper, we share our experiences and the keys to our successful builds to streamline burn patients’ documentation and information. Methods In January 2013, the EMR build team was composed of corporate contractors, dedicated clinical staff from all areas of the hospital that transitioned to the build team, and private contractors experienced in the EMR build process. To our great fortune, our burn team was provided access to four dedicated build team members that worked specifically on meeting our burn team documentation needs. With high level collaboration our team was able to assess foundation abilities of the new system, identify gaps to burn care and collaboratively create and build automated documents to meet our burn needs. In October 2016, the EMR system was implemented with our burn specific documents, flowsheets, and reports. Results Through working with our dedicated build team, we were able to create an electronic Lund-Browder Chart with an avatar that is completed with each admission by our medical team. We developed a fluid resuscitation flowsheet that is documented in real-time; displays fluid resuscitation goals; displays urine output goals. The creation of a standardized wound care note template was necessary as the wound template within the existing EMR system was too cumbersome. Burn wound photo-documentation to include inpatient, outpatient, intra-operative and emergency department needs automatically uploads into the patient’s medical record from an encrypted portable handheld device connected to the EMR. Burn specific reports were developed to meet the specific needs of inquiry whether it is for performance improvement or research. Additionally, the same EMR is used in all phases of care to include the burn clinic which allows for ease and continuity of care. Conclusions An EMR that is all-inclusive has benefitted our team and patient safety by streamlining the review and documentation of information. Having specific and dedicated EMR build specialist allocated to focusing on the needs of the burn unit was invaluable in the build, implementation, and maintenance phases. We continue to work with our EMR specialist to improve processes and documentation practices that impact patient outcomes. Our burn EMR specialist meets with the burn team on a monthly basis to evaluate and assess ongoing needs to further outcomes. Applicability of Research to Practice Within this presentation, we will share our journey, challenges, and successes.

Electronic Health Records: Privacy and Security Issues in a Comparative Perspective

Background Antibiotics are one of the leading causes of emergency room visits for adverse drug events, yet surveillance for antimicrobial allergy adverse events is limited and identifying true cases is challenging. As part of a larger study to improve antimicrobial use, we sought to develop and validate a tool for near real-time measurement of antimicrobial allergy adverse events. Methods An existing cohort of patients undergoing cardiac device procedures with known antimicrobial exposure was split into a development and validation set. Candidate triggers for identifying allergic reactionswere identified a priori, using disease phenotype codes “phecodes”, allergy documentation on allergy module of the electronic medical record (EMR), and keyword searches applied to clinical notes (e.g., “anaphylaxis,” “rash”), medication administration (e.g, corticosteroids alone or with antihistamines) and administrative codes (ICD-10 codes and phecodes). Cases were reviewed for presence of a true event, and the tool was iteratively updated based on chart review findings. The tool was then applied to the validation cohort and a sample of trigger-flagged and unflagged cases underwent manual review. Data were analyzed in SAS and model triggers were selected using a LASSO technique. Results Among 34,703 patients, N=431 cases underwent manual review (350 development; 120 validation), and 104 true allergy adverse events were identified. Among chart reviewed cases, the most frequently detected flags were keywords in unstructured clinical notes (35%), phecodes (26%), corticosteroid administration (15%), observed allergy documentation in EMR (14%) and reported allergy documentation in EMR (13%). The final model contained 7 triggers and had an AUC of 0.95, and a positive predictive value of 67% (Figure). The strongest predictors of true adverse events were the allergy health factors (aOR 358, 95% CI 76.3-999) and specific Phecodes (Table1). Conclusion We developed an antibiotic allergy measurement tool using structured and unstructured data that can be applied to detect antimicrobial adverse events in near-real time. This model may be applied to provide near real-time feedback to clinicians about antimicrobial allergy adverse events and may be useful for antimicrobial stewardship programs. Disclosures Westyn Branch-Elliman, MD, MMSc, DLA Piper,LLC/Medtronic: Advisor/Consultant|Gilead Pharmaceuticals: Grant/Research Support.

Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone. A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified. A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate. Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.

340 Background: Gastrointestinal oncology patients (GIOP) at Fox Chase Cancer Center (FCCC) disproportionately require emergency department (ED) or urgent care (UC) evaluation due to chemotherapy-related adverse events (CRAE). Between January 2014 - June 2018, GIOP comprised 24% of visits to the FCCC ED and 29% of visits to the FCCC UC center, though specific patient and disease characteristics are unavailable. Prior to March 2022 there was no process to proactively contact patients to assess for CRAE or provide symptom management education (SME) following the administration of a new intravenous chemotherapy (IVC). This contributed to a perception of higher volumes of patient-initiated phone calls for acute CRAE management, SME, and UC/ED evaluations as compared to other disease sites, leading to patient and provider dissatisfaction. Methods: We aimed to contact at least 50% of all GIOP starting new IVC through a standardized nurse-initiated phone call within 72 hours of a patient’s first infusion by June 2022. A multidisciplinary team of medical oncology fellows, nurses, and clinic managers launched this initiative through participation in the ASCO Quality Training Program. A series of Plan-Do-Study-Act (PDSA) cycles were conducted over 12 weeks. All GIOP starting a new IVC were electronically identified on a weekly basis by the infusion room scheduling system. Clinic nurses called patients from this list to assess symptoms, provide SME, and advise early intervention for CRAE. A smart phrase was developed for efficient yet comprehensive documentation in the electronic medical record (EMR). EMR documentation was reviewed weekly to determine if calls were made within 72 hours of treatment, which guided subsequent PDSA cycles. Results: From March 14, 2022 to June 3, 2022, a list of all GIOP starting a new IVC was generated and consistently distributed weekly to nurses embedded in 6 GI oncology clinics. Over 12 weeks, 40 (56%) of 71 patients receiving a new IVC were called and 37 (52%) of the patients were called within 72 hours. Of the patients who were called, 93% were called within the intended time frame. Nurses documented their outreach calls in the EMR utilizing a standardized smart phrase to summarize CRAE assessments and SME. Acute or unresolved issues were triaged to the patient’s primary oncology team for further guidance. Conclusions: This initiative successfully introduced a nursing-led outreach phone call to GIOP starting a new IVC, though additional PDSA cycles are needed to achieve more consistent outreach. We plan to standardize outreach to patients with organized SME while striving to automate performance monitoring. Further evaluation of this intervention, which will eventually better identify patients at highest risk for acute unplanned care needs, will assess the impact of patient-reported outcomes and health care utilization.

Background Shared Decision-Making (SDM) is a collaborative process where patients and clinicians work together to determine a treatment plan, balancing evidence-based medicine with patient values. Little is known about how SDM is documented by clinicians in the Electronic Medical Record (EMR). Understanding how patient preferences are reflected in clinical documentation is important as clinicians strive to make care more patient-centered. This study seeks to evaluate whether clinical documentation is reflective of verbal communication in pediatric clinical encounters. Methods This Mixed Methods Sequential Exploratory Analysis included 109 pediatric surgical consultations. For each encounter, the transcript of the verbal clinician-family communication was descriptively evaluated for elements of SDM: discussion of risks/benefits/alternatives, parental preferences, and expression of parental concern. Next, the corresponding EMR documentation was evaluated for these elements. Qualitative methods were used to describe similarities and differences of these elements in both types of communication. A basic descriptive quantitative analysis was conducted to further describe the similarities/differences between these two types of communication describing the same clinical encounter. Results In the discussion of risks/benefits/alternatives, the EMR documentation for 48% of encounters used a standard dot phrase, which often differed from what was discussed verbally. Common discrepancies also included a parental preference being documented in the EMR when no preference was verbally expressed by the parent, occurring in 12% of consultations. The opposite was also seen: in 14% of consultations, a parental preference was expressed but was not documented. Overall, expression of parental concern was infrequent, occurring in 30% of the consultations. Of the 34 parental concerns that were expressed, only 21% were documented. Conclusion In conclusion, there are substantial discrepancies between what is verbally communicated in pediatric surgical encounters and what is subsequently documented in EMR documentation. As clinicians evolve in delivering patient-centered care, understanding how patient perspectives are reflected in medical documentation could significantly impact clinical practice, informing interventions to make documentation more inclusive of patient values. This research is particularly significant as patient care is becoming more transparent with increased patient access to their EMR, emphasizing the importance of understanding whether SDM is accurately reflected in clinical documentation.

Electronic Health Records (EHRs) can improve the quality, safety, and efficiency of patient care. Migration to EHRs is progressing, but has been slowed by concerns related to interoperability, security, cost, patient safety, and usability. This paper focuses on EHR usability, specifically heuristic evaluation, or utilizing accepted guidelines for assessing EHR interface design. Health-care researchers initially applied industry-standard heuristics to EHRs, but subsequently health-care-specific groups have adapted and expanded these standard heuristics, calling for development and use of heuristics specific to EHRs. This paper first summarizes the evolution of heuristic evaluation of EHRs, then discusses the similarities and differences between these various approaches. This is an important step in developing community consensus on integrated heuristics, the basis of successful heuristic evaluation of EHRs. We then discuss the ‘Theory of Fit’ as a means of explaining the existence of these somewhat different heuristics, and close with suggestions for further research.

Documentation using Electronic Medical Records (EMR) significantly improves the quality of patient medical record completion. Siloam Hospital Bangka has implemented EMR; however, several challenges have arisen in its application within the inpatient department. This study aims to analyze the factors influencing compliance with EMR documentation among nurses and midwives in the inpatient department, focusing on aspects of knowledge, motivation, supervision, and infrastructure availability. This study employs a quantitative approach with a cross-sectional design. The sample consists of 33 nurses and midwives in the inpatient department, selected using a total sampling technique. Data were collected through questionnaires and an audit observation checklist of inpatient medical records during the period from January 15 to January 22, 2025. Fisher’s exact test and multiple logistic regression were used to determine the dominant variables influencing documentation compliance. The research results indicate a significant relationship between knowledge (p-value = 0.000; OR = 184.000) and supervision (p-value = 0.000; OR = 46.000) with nurses and midwifes compliance in documentation. However, no significant relationship was found between motivation or infrastructure availability and documentation compliance. This study concludes that documentation compliance is influenced by knowledge and supervision, with knowledge being the most dominant factor. Since documentation compliance in electronic medical records supports the quality of healthcare services at Siloam Hospital Bangka, the hospital is recommended to implement regular training programs on the use of electronic medical records.