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Agh Launches Electronic Medical Record

A year after beginning the project, Atlantic General Hospital is ready to launch PERKS, or the Patient Electronic Record-Keeping Service. The new system, which is scheduled to go live January 28, digitally links all documentation and physician orders for care throughout the inpatient and outpatient units of the hospital. So, no matter where a patient’s entry point or how many services received, his or her caregiver has access to a full record updated in real time.

Electronic records provide a number of benefits, including improved efficiencies in care because the incidence of duplicated testing is reduced. Electronic records also eliminate time lost tracking down paper records from other departments or pulling information from disparate systems. There are substantial patient safety benefits, such as alerts that pop up in the system to warn of potential errors. PERKS allows for:

Electronic physician order entry. Previously, when physicians ordered testing, prescribed a medication or outlined a treatment plan for a patient, they wrote down what was needed and gave the information to a unit secretary, who then typed it up and either faxed it or sent it electronically to the appropriate department to carry out. The PERKS system streamlines the process: the physician directly enters his or her orders from a computer tablet where the information is captured in the electronic system. PERKS transmits the order to the appropriate department for action. The process is streamlined, and there is less chance of error caused by misinterpreted handwriting or transcription inaccuracies.

Built-in clinical alerts. The clinical staff at Atlantic General worked closely with the IT staff during the development of PERKS to ensure that appropriate alerts and pop-ups were built into the system to warn clinicians of potential problems with the care being administered. One prime example pertains to prescribing medication. If a provider tries to order a medication that is on a patient’s allergy list or that will conflict with another medication a patient is already taking, this will prompt an alert in PERKS.

“Clinicians have always attempted to assure we never order medications that are contraindicated by another drug or by an allergy of the patient. With the thousands of available drugs, it is impossible to know all of the potential contraindications. However, with PERKS’s assistance we can process data from many sources electronically in seconds, providing immediate notification to the physician of a potential problem before it is ordered,” said Colleen Wareing, vice president of patient care services at Atlantic General Hospital.

Medication barcoding. In 2008, Atlantic General instituted a barcode scanning system that allowed the nursing staff to scan a patient’s wristband and confirm in a computer system that they had the correct patient as well as the correct medication orders for the patient. With PERKS, the barcoding has been expanded to the actual vial or package of medication, which allows the nurse to validate the correct drug, dose, route and time for administration. The nurse now scans the barcode on the patient’s wristband and then scans the medication the pharmacy has prepared. Any conflicts with the five rights of medication safety – right patient, right medication, right dosage, right time, right route – will result in an alert in PERKS.

Improved patient rounding and care coordination. With all departments connected to one system, a patient’s complete “chart” and plan of care is available for instant review. The interdisciplinary team, which includes the physician, nurse, pharmacist, therapists, dieticians, chaplains, nurse case manager and other specially-trained associates meet each morning to review inpatients’ care and plan for the day. This team can pull up new radiology studies, lab results and clinician notes much more quickly because there’s no lag time. As soon as tests are completed, the results are available in PERKS. And, the system can be accessed by the caregiver right in a patient’s room through care.connection, the new multi-media devices that went live earlier in January.

Atlantic General began its journey with electronic medical records in 2008, when it installed an electronic medical record system in its Atlantic General Health System outpatient physician practices. The organization pushed on to install the electronic system in its Emergency Department in 2011, and they have spent the last 12 months expanding PERKS to the entire hospital.

“This has been a very solid implementation,” said Barbara Riddell, Atlantic General’s vice president of information services. “I have been through many implementations in the last 16 years and this one has been an excellent journey, with the clinical and business team in the hospital working closely with our vendor partners to build a system that always puts the patient at the center. The transition has been smooth, which was made possible only through outstanding team work.”

In 2012, these efforts allowed Atlantic General to achieve Stage 1 Meaningful Use, a federal mandate that requires hospitals install electronic medical records by 2014. Atlantic General Hospital is one of only two hospitals on the Eastern Shore to reach this status. They are ahead of more than three-quarters of U.S. hospitals in doing so, based upon a recently published federal report.

“We are in a unique position as a community and as a hospital in this community, because of our ability to coordinate care throughout Worcester County and southeast Sussex County,” said Michael Franklin, president and CEO of Atlantic General Hospital. “Through Atlantic General’s efforts, this community will have the most advanced system of care available.”