Module 1: Question 2

Approximately 2 years ago we moved to the EMR. Literature has addressed apprehension and resistance from the older generation; however, I found that some of our “seasoned staff” knew that technology was upon them and there was no way out apart from retirement ( an unwise decision in a floundering economy?) and so many of them embraced this change by greeting technology and becoming superusers. To their credit, I think that they recognized the value in standardized documentation. CPOE is coming in the spring and again we are preparing our staff for the implementation of change. I am glad to see that a common thread in most conversations about CPOE is prevalent: patient safety.

When I began my nursing career, information was kept in three ring binders scattered around the unit. Now patient information, past and present health care records including labs, medications, progress, and interdisciplinary plan, is available from one location. Standards of practice, chemotherapy protocols and drug administration policy and procedures, patient incident reporting, etc are readily accessible. I trust the information that I retrieve is current. I trust that uniformly updating information systems is much more easily achieved today than locating every three ring binder.

Standards have been key in communicating with the main hospital and other facilities. Standards on cancer staging with the use of imaging is important as patients may be treated at different facilities over the course of their disease. The EMR has made the reconciliation of medication information easier. Patients going from the Huntsman to the main hospital or elsewhere in the community avoid omissions, duplication , dosing error, and drug interactions. I see daily use of NANDA terminologies that help nurses identify which patient care issues/diagnoses they can treat independently. I believe nursing is a profession so I am a fan. Gimme an “N”!

Advanced practice nurses and physicians deal with coding DRGs for billing and reimbursement purposes. My exposure is limited; however, after speaking with some physicians, I found that they felt that the retrieved information is too broad and did not accurately represent the interventions provided. Due to this, it was difficult to use any of the information with regard to research, public health, or policy development. On the other hand, some report that although accurate coding requires training and is dependent on the interpretation of the individual, auditors are able to identify who is being billed at higher levels than the care provided.