SMART CHARTING Is going paperless worth it? Brooke Alire, RN, of Community Hospital in Grand Junction, Colo., thinks so.

The Year of the EMR Conversion. That was 2012, nothing but contracts, interfaces, workflow analysis, programs, servers, wizards, procedure cards and pick lists. Planning and implementing an electronic medical records system required hard work, long days and learning a new lingo, but now that it's done we're beginning to reap the benefits.

What did all that work gain for our hospital's surgical services department? Precious time. More time with patients, less time documenting, less time gathering performance data.

Our new EMR provides all the documentation prompts, procedure cards and actionable data we need. It also tracks our performance, manages our supply chain, interfaces with the billing department and facilitates patient throughput. Can you tell I'm enthusiastic about this system?

Recapping the journey
At times that enthusiasm flagged during the implementation process. I shared our hospital's journey to EMR implementation with Outpatient Surgery readers in a 6-part series last year. There were plenty of false starts along the way (tinyurl.com/9444vdk).

After evaluating 4 different systems using an 80-question matrix, we chose the EMR system that met all the identified organizational objectives for Community Hospital Surgical Services, with its 3 surgical facilities with a total of 8 ORs and a staff of 75. Our new system is Windows-based, replacing our DOS-based system, which was cumbersome to use and didn't provide support to clinical staff or management.

Signing the contract didn't mean smooth sailing all the time. Our go-live date was pushed back more than once due to various issues, such as creating the interfacing necessary to work with our existing HIS throughout the hospital, including accounting and materials management. Quality patient care is the goal, but you can't provide that if you don't get paid for your services.

HEAD CHEERLEADER Break out the pom-poms during EMR implementation, says Annette Saylor, RN, CNOR, CRNFA.

EMR project pays off
We went live on March 19, and we're still in what I call the clean-up process. We have realized many benefits from our new EMR system, including:

• Less time spent on procedure cards. With the old EMR, preference card management was time consuming and tedious. There were electronic cards for every different variation of each surgery per surgeon. Editing the cards required using function and arrow keys and difficult DOS formatting. Now the cards are condensed to include all the variations in a single card and can tie multiple similar procedures to the same card. Changes to equipment, positioning, padding, instruments and supplies, even the radio station the surgeon likes to listen to, can be completed globally in a few clicks.
• Increased quality of care. Our nurses document by exception now. Because 80% of a surgery is the same for every patient, that documentation populates as the RN moves through the chart. The 20% that is different is then selected from canned text with a click of the mouse instead of narrative charting the whole surgical record. This saves time; less patient and staff time is wasted in gathering patient information, which impacts quality of care and patient satisfaction. Take allergies, for example. With the old system, when a nurse documented patient information at preadmission, she asked about allergies and recorded that in the patient record. Then the next nurse down the line asked the same question and documented it; then anesthesia entered the room, asked about allergies and ... you get the picture. With the new system, that data flows all the way through. Complete patient information is in front of you — allergies, assessments, surgical history, medical history — and you present competent staff communication to the patient.
• Less time spent gathering analytical data. Our chief medical officer recently asked for a list of the surgeries our surgeons performed in the past 6 months. What would have taken me 6 to 8 hours to compile I was able to print out in 5 minutes — complete with graphs and tables. And with data at my fingertips, we can benchmark our performance against other hospitals and facilities using a nationwide standard for documentation, not our old homegrown documentation.
• More precise ability to monitor costs. I can open the analytics page and see the downtime for each OR, where it's occurring, turnover and why there are delays. I can see outlier surgeons that are costing us more to do a specific procedure. All this data helps me create plans to improve our throughput.
• Better patient tracking. Our split screen details patient location and provides proactive management of patient throughput, thus enhancing capacity management. That leads to better staff utilization throughout the entire department.

What I learned
As our nurses get more familiar with the system, their documentation time is decreasing. They're spending less time monkeying with the computer and more time at the bedside doing patient care. All these positive outcomes required planning, including input from all who use the system, and lots and lots of education. When I think back on this past year and a half, here are the lessons I learned:

1. Get buy-in from as many stakeholders as possible.
2. Dedicate sufficient fulltime staff to work on implementation.
3. Name an informatics RN system administrator.
4. Ensure IT participates during implementation to avoid delays in interfacing or going live. But don't let IT drive implementation or else the end result will be what meets their needs, not your clinical needs.
5. Appoint a project manager that isn't the director of the surgical services department. It's hard to do both jobs well.
6. Choose a system with flexibility that allows you some autonomy to make changes. When we discovered the system preparations list had nurses prepping patients before positioning (we do it the other way around), we were able to change the list to match our actual workflow.
7. Training, training, training for all users. Training continues all along the way.
8. Be upbeat, because many people are intimidated by technology. I'm proud that we didn't lose a single staff person because of technophobia. Also, the EMR core staff needs to get all the encouragement and praise you can muster because the process can be discouraging at times. Get out the pom-poms!
9. Buy the system you want. Don't let price dissuade you — know that you can always purchase additional capabilities later. When we purchased our system, we had to give up some things that weren't essential to achieving our goals, but they were the "wow" things we'd love to have. What we bought is doing exactly what we thought it would, if not more than we dreamed.
10. Negotiate, especially at the end of the fiscal year, when EMR vendors have sales quotas to meet.

EMR LAMENTS
Regrets? They've Had a Few

A short list of what Outpatient Surgery Magazine readers wish their EMRs could do:

• "It should be able to integrate with all other healthcare facilities and providers to fulfill the vision of what it was meant to be. This unfortunately will not be the case."
• "Review all current medications as a group rather than individually. Many of our patients have 15 to 20 medications and each needs to be reviewed/renewed on each visit."
• "A fully integrated system, not a bunch of hodgepodge interfaces."
• "Need two-way communication between hospital and clinic records. Currently, hospital reports go to clinic, but no clinic records can go to hospital."
• "EMR delivers a slower, much poorer quality, more expensive documentation system than the trained nurse's brain/eye/hand delivers with well-designed and formatted paper medical records. Experienced nurses cannot stand using them. Doesn't this tell us something?"
• "In a fast-paced environment, patient satisfaction and safety are key, and focusing on a computer screen instead of the patient does not accomplish those goals."
• "Our software doesn't always act nicely with our scheduling system."

Source: Outpatient Surgery Magazine Reader Survey, January 2013