Medical Error Reduction Proposition

Much has been written about medical errors and the EMR. The EMR has been touted to decrease medical errors by several mechanisms. On the surface, it eliminates errors and problems associated with misinterpretation of illegibility. Illegible notes, orders, and handwritten prescriptions have been documented to be a major source of errors. CPOE holds the potential to make orders more explicit and less vulnerable to misinterpretation resulting from errors in construction and syntax in the creation of handwritten orders. Furthermore, orders may be implemented more consistently as a result of properly imbedded clinical decision support at the point of order entry. This includes such devices as the attachment of commonly used appropriate order sentences to medication orderables, the development of computer- based order sets that may act as prompts to prevent errors of omission, and the judicious use of rules and alerts to guide safe and proper execution of orders. Although CPOE holds great promise for reducing medical errors in orders, it should be kept in mind that other processes for ensuring safe administration of medications, such as bar coding or radiofrequency identification tying patients to dose dispensing of medications may be equally important in this regard. Electronic documentation has the advantage of facilitating clear, legible communications in standard formats that can be viewed from any computer workstation. Transitioning entirely away from paper processes holds the promise of greater efficiency in workflows with improved effectiveness, giving physicians and nurses more time to spend with patient care. The EMR has the potential to do more than just decrease medical errors. The EMR may improve outcomes directly through the embedding of best practice standards in the form of decision support at the point of order, prescription, or documentation entry. It is tempting for the hospital and medical staff to grossly underestimate the resources necessary to design and build a complete EMR environment that will meet these expectations that are necessary to achieve the anticipated benefits of a successful implementation. Furthermore, these benefit assumptions have been challenged by conflicting reports in the literature that include wide ranges in outcomes following a transition to the EMR most likely resulting from variations in vendor technology, EMR design and build, and implementation strategies. Finally, measuring benefits from the EMR is a shifting proposition, owing to changes and improvements in hardware and software technologies that make prior reports of outcomes rapidly obsolete.

Preplanning for the EMR—Analysis and Documentation of Clinical Processes and Workflow: Current and Future State

To be successful, the process should begin with reengineering both clinical and business processes. This should always begin with a careful workflow analysis of all clinical processes from the bedside through all of the clinical support departments, both for the current state and as expected to be leveraged in future state.

As an organization, it is a must to think in terms of how physicians, nurses, clinicians, and clinical support staff work, and how a patient needs to be processed through the hospital, regardless of health issue, and inclusive of all clinical departments. Lean/Six Sigma methodology may be very useful in crafting a structured approach to design and implementation when coupled with formal project management.

■ Initially, an upfront systems analysis detailing workflow must be accomplished that will address current state and future state after implementation of any EMR application, a process that will require input from all relevant stakeholders.

■ Workflow must be considered at all points in the clinical process. A detailed process and data flow diagrams should be designed for each clinical process, clinical unit, and clinical support department to indicate patient flow, patient data flow, and detailed workflow processes for all staff. Foremost, the patient must considered at the center of the process.

■ The flow diagrams may now be used to examine weaknesses in the current environment and then pose possible solutions for improving patient care and data flow, creating new flow diagrams. Comparing current state with the new flow diagrams allows users to easily visualize and become more creative in seeing new opportunities.

■ Finally, a subsequent flow diagram may be constructed, depicting how work- flow could be improved if electronic systems were in place to support the needed functionality. To achieve optimal process improvements, one must “get outside the box in thinking.” This process provides an important time to pause and carefully consider, not to redesign the current system that already exists and will not meet future needs, but rather to think future, think work- flow, think process, and think reengineering. Most of all it is critical to think in terms of optimal patient care.

Most healthcare organizations may be tempted to make the mistake of expending valuable resources redesigning what they are already doing, thereby missing this vital opportunity to reengineer processes and better leverage information technology. No organization can take advantage of computerized applications if the objective is to continue to do things the way they have always been done. Design teams must think outside the box, a point that needs to be stressed over and over to the team. Once current workflow, a desired workflow, and reviewed processes that must be reengineered have been defined, workflow may be aligned to the order entry applications design and build.

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