A state-of-the-art EHR system offers intuitive clinical decision support systems (CDSS) to enable clinicians to make better treatment decisions in real-time. CDSS tools take many forms but most EHR systems fail to adequately address this need. Instead, as we addressed in our October blog, most offer one-size-fits-all, cookie-cutter solutions which fail to capture the nuances of individual patient care. Simply put, EHR systems without customizable CDSS tools cannot accommodate the ever-growing demands on healthcare practitioners.
Part of HarmoniMD™’s uniquely flexible solution, and one of its core competencies, is protocol-driven Electronic Clinical Documents (ECDs). These incorporate the best treatment options and clinical expertise available, resulting in consistency of care, regulation compliance, and reduction of errors. Through ECDs, YOU map the workflow you want your clinicians to follow and provide guidance on clinical choices. Rather than having a design imposed upon your team, you—as the experts in best practices for your field, your facility, and your workflow—can modify any ECD from our extensive library based on years of clinical experience, or design one from scratch.
ECDs mimic in a very intuitive way the paper Patient Chart that all doctors and nurses are familiar with, while at the same time integrating clinical decision support and protocols. Reports can then be generated to easily track whether or not these protocols are followed. To name just one example: Pain medications the Medical Executive Committee recommends for a specific condition can be listed from mildest to strongest, allowing physicians to easily order from a curated list, secure in knowing they are following facility guidelines and medical best practices. Reports can then show which of these pain medications are most often ordered and when a physician chooses to deviate from this list, informing clinician supervision and the regular review of practice protocols.
Since any data entered in an ECD can be included in a report, reporting for a variety of purposes is easily accommodated including governmental compliance, QA, and supervision. And since care is standardized, assisting the user with the data capture process by structuring the entry of clinical information, so is reporting.
From within an ECD, data can be entered into the Patient Chart (such as orders, diagnosis, vital signs, allergies, etc.), rather than requiring clinicians to navigate to different sections of the Patient Chart (resulting in dreaded multiple clicks through the system). In other words, ECDs guide a clinician through the Patient Chart, in the specific order that your facility, department or specialty deems best. In this way, ECDs not only aid clinicians in making rapid decisions to increase the efficiency of care, but also increase the consistency of care. And ECDs can be tailored for the unique needs of physicians and nurses alike.
Critical ECDs for physicians include condition-specific Order Sets, with recommended predefined orders that can be preselected or optional. The details of the orders within these ECDs are all specified by the clinical team responsible for designing the Order Set. One example is a PRN medication standardly ordered for a specific condition. This medication can be preselected (complete with data already entered such as the dosage, route, and notes on when to administer). The ordering physician doesn’t even need to click once to order the medication: It will be ordered automatically when the order is signed, unless deselected. Other preselected or optional orders can include lab tests, procedures, imaging orders and nursing activities. And the ECD can also contain documentation for vital signs and other clinical information that might be captured at the time the order set is being filled out.
ECDs specifically for nurses are also critical for adhering to practice protocols. Nursing documentation is an often-overlooked area of activity that can directly impact the quality of care that patients receive, best practices, and compliance. These include wound care, post-operative care, nursing assessments, adverse event and incident reporting, and more.
Standardized protocols, instructions, educational tools, alerts, and reminders can be built into any ECD, providing clear expectations and guidance to staff from any clinical specialty. This improves documentation and communication between clinicians and reduces time spent waiting for results to be conveyed between departments. Other common ECDs include Physical Therapy Evaluations, Blood Transfusion Documentation, Patient Intake History, Preoperative Safety Checklists, Discharge Forms, Operative Reports / Postoperative Instructions, Radiotherapy Treatment Sheets, Hemodialysis Treatments, and more.
We know from experience that when converting to ECDs, documentation times are often cut in half while dramatically improving compliance with best practices and reporting requirements. One Physical Therapy department we worked with reduced their documentation time by two thirds, in part because they were able to design ECDs to very specifically mimic their workflow and select from a variety of entry fields that worked best. (Review specific options available in constructing ECDs on this page of our website.)
Your patient care may also involve unique aspects that no one else addresses. For example, one of our clients tracks pollution exposure during pregnancy and needs to ask if the fetus has been exposed to open-flame cooking. ECDs easily accommodate unique needs such as this because they do not require any reprogramming of the underlying database. This means that not only are they flexible enough to document any clinical process, they can also be built, and built quickly, in any language. This becomes invaluable when patient populations speak one or more secondary languages and need consent forms in those languages.
Please contact us for more information on how Electronic Clinical Documents can assist you in ensuring your practice protocols are consistently adhered to throughout your organization. We look forward to hearing from you.