UPMC Creates Electronic Health Record
UPMC has undertaken a concerted effort to create a secure and comprehensive electronic health record called eRecord. Various applications of this technology are being rolled out in multiple phases across the health system.
Each application addresses two central goals:
- to improve the quality of care delivered to patients
- to enhance the effectiveness and efficiency of the health care organization
UPMC’s eRecord applications are advancing the quality of patient care in several ways. They are replacing paper charts, which can be misplaced or damaged. With the development of eRecord, the need to maintain a paper trail of vital signs, prescriptions, and test results is being eliminated. Physicians and other caregivers can view x-rays, review test results and lists of current medications, and ship prescriptions to the pharmacy without the need for pen and paper.
Physician orders will no longer be written, which eliminates concern about legibility. Best of all, caregivers will be able to pull up information at the patient’s bedside rather than search for patient charts kept at the nursing station.
Eliminating the Drawbacks of Paper
The development of eRecord eliminates much of the potential for error. For example, computerized physician order entry (CPOE) is reducing the need for doctors to write their orders on paper and then store those paper records in charts. By using CPOE, questions regarding the legibility of handwritten orders or the availability of the patient chart are eliminated.
One of the most widely used eRecord applications is Results Review (PowerChart). This application provides clinical patient information in a unified manner, much like the paper chart, without many of the drawbacks of paper. It has the ability to display:
- laboratory data
- microbiology results and sensitivities
- preliminary and final radiology results
- preliminary and final electrocardiogram readings
- pulmonary function studies
- pathology reports
- preliminary and final cardiac catheterization studies
- dictated progress notes
- emergency department visits
- operative reports
- discharge summaries
At the same time, PowerChart provides decision support and alerts for a multitude of events, assisting caregivers with decision making. This data can then be shared among physicians and other caregivers at different clinical sites, ensuring timely clinical decisions and optimizing patient care.
‘Information is Power’
It didn’t take very long for Ibrahim Ghobrial, MD, to become a strong advocate for UPMC’s eRecord.
After using eRecord for just a few weeks, Dr. Ghobrial, director, Ambulatory Services, UPMC McKeesport, concluded that UPMC’s informational technology is a valuable tool that improves the efficiency of physicians and their staffs and further enhances patient safety.
He notes that by using eRecord, physicians can immediately access a wealth of important patient information when they need it, even outside traditional business or work hours. Physicians also can use eRecord to review and enter data from a variety of clinical events, and practitioners have real-time access to patient test results.
“The more information you have, the better care you can deliver. Information is power, definitely,” Dr. Ghobrial says.
He adds that the eRecord applications only can be accessed by authorized practitioners using unique passwords. The benefits of replacing paper medical record and charts with electronic records are immeasurable. Paper records can be lost or misplaced, and the time spent searching for them or waiting for them to be found can be better used interacting with patients or members of their families.
“The applications within eRecord also enable the physician to complete clinical documentation, transcription, family histories, procedure histories, and a variety of other tasks online. This feature addresses important legibility issues and reduces the need to call a physician to clarify handwritten notes or orders. Online documentation is organized in clear, concise formats, which eliminates the task of interpreting handwritten notes sometimes placed in the margins of paper records or scattered throughout other parts of the paper forms,” Dr. Ghobrial says.
Addressing ‘Sound-alike’ Drugs
Dr. Ghobrial has been particularly impressed with the automated prescription-writing feature of the eRecord.
“There has been an explosion in the number of new medications available today in health care. As a result, there are now many ‘sound-alike’ drugs. For example, the drug Combivir (administered for HIV treatment and prophylaxis) is very similar in pronunciation and spelling to the drug Combivent (an inhalation aerosol used to treat asthma),” Dr. Ghobrial says.
The automated prescription-writing feature of eRecord addresses the proliferation of sound-alike drugs by listing both the brand name and the generic name of the medication. Physicians also are prompted to click on the appropriate box to note the dosage level they wish to order. “Some physicians-in-training may not be aware that certain drugs such as Flovent inhaler come in different strengths. There is a prompt that will help them remember the importance of ordering the desired dosage,” says Dr. Ghobrial, who also oversees residents in internal medicine at UPMC McKeesport.