The hospital is a 2.8 million-square-foot campus, located in North Texas. It had been rebuilt to become twice the original size and opened its doors in 2015. The reconstruction was designed to meet the ever-changing needs of Dallas County, one of the largest, fastest-growing regions of the country. The hospital’s most well-known facilities include a Level 1 Trauma center, the second-largest civilian burn center in the US, and a Level III Neonatal Intensive Care Unit. The system also incorporates 20 community-based and 12 school-based clinics. The increase in size was among the major improvements that have been made: the new hospital provides 878 single-patient rooms with private bathrooms and space for families and visitors.
The institution remains one of the nation’s busiest public hospitals, with more than one million patient visits each year. It is also the primary teaching hospital for the University of Texas Southwestern Medical Center. I have been working for this facility in various roles for more than 22 years, and I am proud to be a part of such an established institution that facilitates change and improvement. Due to the COVID-19 pandemic, the interview was conducted over the phone on August 17, 2020. The interviewee was John Do MHSM, MBA, BSN, RN.
According to the information provided by Do, the facility started Epic implementation in 2005 (personal communication, August 17, 2020). There were three phases to this process: first, all Health Unit Clerk (HUC) practices were shifted to the system, then, between 2006 and 2008, the Ambulatory clinic completely moved into Electronic Medical Record (EMR), and, finally, in 2008, computerized physician order (CPO) entry was initiated (J. Do, personal communication, August 17, 2020).
The introduction of EMR combined stepwise and “big bang” approaches. In Outpatient Clinics (OPC), a group to group strategy was used while the Inpatient department transitioned all its operations into the system simultaneously (J. Do, personal communication, August 17, 2020). In the facility I worked, the implementation was made with the help of so-called “superusers” – trained staff members who received two-hour online training and 72 hours of face-to-face training from the informatics department.
Then, they became responsible for educating other employees in the area assigned. In the first stages, only a few representatives from each department were selected for the training, and I was among them. We were provided with red shirts with the “Epic superuser” inscription for easy recognition.
The implementation of Health Information Technology (HIT) was facilitated by the Federal government. The first steps were taken in 2004 when President Bush signed the Health Information Technology Plan, but the main role was played by the American Recovery and Reinvestment Act (ARRA) enacted in 2009 aimed at the broad modernization of the country’s infrastructure (Guarmati, 2016; Centers for Disease Control and Prevention, 2009). The Health Information Technology for Economic and Clinical Health (HITECH) Act demanded the introduction and meaningful use of electronic records (Centers for Disease Control and Prevention, 2009).
There were several practical reasons for EMR implementation. Most importantly, it provides convenient access to patients records fostering efficient communication and coordination and assisting in clinical decision-making by ensuring better diagnosing and safer prescribing. EMR helped to eliminate certain problems which had been commonly seen in medical practice. For instance, paper charts took up a lot of space, and searching for them used to be time-consuming and labor-intense hindering healthcare efficiency.
However, there were also several difficulties associated with the introduction of EMR. One of the challenges was staff resistance – many nurses preferred to retire rather than adapt to a new way of practicing. Another problem was connected to customer satisfaction – there were many reports that working with electronic medical records diverted nurses attention from face-to-face interaction with patients. During the adaptation period, a significant reduction in workflow efficiency was noted. Also, it was noted that when Best Practice Alert (BPA) fires as soon as a medical practitioner opens the chart, many tend to ignore notifications without reading and taking the necessary actions. As a result, multiple medical errors can occur.
Using health information technologies in medical practice can be helpful in various ways. EMR acts as an error prevention tool by automatically checking for any problems when a new medication is prescribed, ensuring that the drug is safe considering a patient’s medical history, allergies, and other medicines they take (Alotaibi & Federico, 2017). EMR, in general, allows better communication and analysis of medical information (EMR software benefits, n.d.).
One of Epic’s largest recent updates was the introduction of prescription drug monitoring program (PDMP). This system allows healthcare providers to monitor substance prescriptions and notice if some patients misuse opioids or are at risk of overdose (Centers for Disease Control and Prevention, 2020). In my practice, a medical professional is expected to check PDMP before prescribing any controlled substances to a patient at the time of discharge.
To monitor quality measures, the hospital in question uses EMR’s database to evaluate the outcomes. For example, Hester Davis Falls Risk Assessment Scale is used to access the fall and fall prevention rates. We also employ HD Emergency Department Falls Program designed for ED patients.
Do mentioned that the significant cost savings observed as a direct result of using EMR were better reimbursement and meaningful use incentives (personal communication, August 17, 2020). Using health information technologies also helped reduce spending on transcription, storage, and re-filling of medical records (The Office of the National Coordinator for Health Information Technology, n.d.). Moreover, EMR provides more efficient documentation and better billing accuracy (The Office of the National Coordinator for Health Information Technology, n.d.).
There are many updates to Epic in progress. According to Do, the organization’s informatics committee meets monthly to discuss the issues they are facing (personal communication, August 17, 2020). The team is currently working on streamlining Best Practice Alerts (BPA) to alter the tendency seen among many practitioners to snooze them without reviewing (J. Do, personal communication, August 17, 2020). Other projects include working on protocol orders to make more details available and improving records entries to prevent documentation duplication (J. Do, personal communication, August 17, 2020).
Another major initiative is suicide screening. The facility is currently working on converting to ASQ (Ask Suicide-Screening Questions) Toolkit from the Columbia suicide screening tool (J. Do, personal communication, August 17, 2020). ASQ is a free resource for suicide risk assessment designed for medical facilities and can be used both with adults and teenagers (National Institute of Mental Health, n.d.). It presents four questions; a positive response to one or more of them can be considered a warning sign demanding further examination (National Institute of Mental Health, n.d.).
One of the major lessons I have learned from being an active member of Epic implementation was the importance of finding a balance between meaningful and efficient use of medical information technologies and active communication with patients. Significant dissatisfaction noted among clients when healthcare practitioners paid too much attention to the computer screen during their visits helped me acknowledge that it is essential to maintain a dialogue and regular eye contact with patients. It should be the responsibility both of healthcare specialists and leadership teams to develop strategies and solutions to facilitate quality communication while still making the most of the technologies.
From that experience I learned to keep eye contact with patients during the visits paying full attention to our communication instead of filling in charts. Only when they have some questions or concerns, I turn to the computer to provide them with answers or look up tests results. In my current practice, each room has a computer installed the way a medical practitioner never turns back on a patient. In the clinic setting, we usually carry portable laptops and fill in charts while facing patients.
Since my role has changed from a RN to APRN, in the future, I will be more focusing on evidence-based practice. Healthcare providers must ensure the safety of their patients. Therefore, I always review their medical history through the records and use the PDMP tool before prescribing the controlled substances. Another critical challenge I am aware of and try to limit is medical errors occurring due to clinical data being entered incorrectly.
For instance, during patients admission assessment, when RN perform medication reconciliation, they do not always verify with the pharmacy to see if the data is correctly entered in Epic. As a provider, I go over the medication list with my patient to avoid medication errors. Another practice change I remember making was using smart phrases such as “usage of” which can ensure more efficient documentation. However, it is essential to reread the materials and delete all the unnecessary information to avoid mistakes.
Alotaibi, Y. K. & Federico, F. (2017). The impact of health information technology on patient safety. Saudi Medical Journal, 38(12), 1173-1180.
Centers for Disease Control and Prevention (2019). Public health and promoting interoperability programs: Introduction. Web.
Centers for Disease Control and Prevention (2020). Prescription drug monitoring programs (PDMPs). Web.
EMR software benefits. (n.d.). 1st Providers Choice. Web.
Gyarmati, S. (2016). Electronic health records: What are HIT, EMR, and EHR? Stark County: Mental Health and Addiction Recovery. Web.
National Institute of Mental Health (n.d.). Ask suicide-screening questions (ASQ) toolkit. Web.
The Office of the National Coordinator for Health Information Technology (n.d.). Medical practice efficiencies & cost savings. Web.