By Denise Bertin-Epp
July 29, 2010
Medical Record Keeping. Those words alone evoke images of lost charts, delayed orders, mislaid test results, broken paper trails, filing frustrations, time inefficiencies, transcription errors and hunts for charts somewhere on physicians’ desks.
At Brighton Hospital, a licensed addiction center, those scenarios are pretty much nonexistent today, thanks to an innovative, electronic record-keeping system we have been working with for the past four years.
It all goes back to our mission: Put patients first through quality, forward-thinking programs, from assessment to aftercare.
With most of our energy focused on the patient’s recovery, it’s easy to lose sight of the many sub-layers that can be improved upon for the greater good of an addiction treatment and dual diagnosis facility such as ours. It’s like a great recipe. It doesn’t turn out perfect unless all the ingredients are just right. When it came to information systems and record keeping, our hospital had a critical need to put our entire staff’s activities (from doctors to office clerks) under the microscope and take a good look at our recipe — the ingredients and the methods that make up our organization.
The outcome? We discovered that we needed to make some changes. Minor inefficiencies tend to crop up in most organizations, if they’re not reviewed on a regular basis. It wasn’t that they interfered with our patient care, but addressing them certainly takes our organization to the next level.
So what does paperwork and record keeping have to do with quality patient care? In today’s fast-paced digital world, a lot. By collaborating with health record experts at Medical Communications Systems (MCS), we initiated a system (Electronic Behavioral Health Record — ebhr) that not only helps our practitioners to concentrate on providing superior patient care to those who struggle with drug and alcohol dependency, but also streamlines and consolidates the collection, sharing and reporting of clinical data.
The overhaul began with a thorough review of how our staff performed its day-to-day duties. We even hired consultants who had worked with the United States military to help ensure and explain how we could eventually execute a precise, error-free system, one that must be 100 percent reliable.
To implement the system, we had to assure members of the staff that they would eventually welcome the new process with open arms. At first, many, especially physicians, were reticent when it came to the reality of a paperless, electronic system. How is it possible, they wondered, that with the click of a few buttons, symbols and codes, they would be able to input important, specific data that would be easily filed and retrieved? But within two weeks, those who were leery and somewhat uncomfortable with technology were completely satisfied with the new system.
Today, the user-friendly program (including the screens), which has been in place since 2006, supports all aspects of behavioral and addiction treatment, and integrates all of our levels of care, from assessment and discharge to aftercare follow-up, from mental health reviews and lab results to prescription analysis and pharmacy. We are happy to report that there is virtually no redundant record keeping.
ebhr proved to be a most-efficient program — the time and effort previously required to perform simple tasks (a doctor writing a prescription or transcribing a consultation, for example) have been significantly reduced. The system even can question and approve prescriptions because it now carries detailed information on each patient’s medical and prescription history, thereby eliminating the possibility of prescribing drugs which may not mix well with those already prescribed, not to mention allergic-reaction issues.
As for legibility challenges, they’re out the door. Consider, too, that the patient’s privacy rights are all preserved with this system. These efficiencies offer the staff opportunities to develop new and exciting patient programs and spend more time on patient care.
Getting back to our mission of compassion and putting patients first, this system allows us to provide patients — and their families — peace of mind. Thanks to an electronically unified, care-and-recovery-focused treatment plan, we create clear, easy-to-access goals … all with the click of a key, or two.
Denise Bertin-Epp is president and chief nursing officer at Brighton Hospital. Bertin-Epp has more than 20 years nursing and medical consulting experience. She can be reached at depp@brightonhospital.org.
The ebhr system, created with Medical Communications Systems (MCS), is geared specifically for the behavioral health industry. To learn more, contact Greg Cavanaugh at gcavanaugh@medcomsys.com.