What changes when a Long Term Care (LTC) facility transitions from paper charts to electronic health records for clinical documentation? Quite a lot, as staff at Aberdeen and Glengarry have experienced since they activated electronic clinical documentation, patient care orders, advanced care plans and eMOST this spring. Aberdeen went live February 12, while Glengarry started “ClinDoc” on April 22.
Visiting both sites a few days after “Go-Live”, some differences are already evident. Workstations on Wheels (WoWs) become a key tool of clinical and medical staff. Support team members, including clinical informaticists and “powercoaches” sit shoulder-to-shoulder with staff at the nursing stations, reinforcing the learning that staff have undertaken and giving pointers to make it easier.
EHR tools bring new ways of interpreting information, communicating with team
In the first few days, most staff are thinking about the new procedures and learning the new tools. That is where a Powercoach like Trang Cabrera is a good person to have by your side.
“Most of the care staff are taking to IHealth and ClinDoc very well and most people are excited for change and to improve their Documentation process. I know it’s a slow process start right now. But they feel supported,” says Cabrera, working at Glengarry.
Occupational Therapist Jenny Zedel, who has been working on her documentation with Cabrera, can already see how useful the electronic health record (EHR) is going to be for her work.
“It’s actually easier to find information and then click. Communication lines will be a lot stronger between all the different disciplines. It’s just easier to get multiple different messages out to people and whatnot, so I’m excited for that,” says Zedel.
“I think communication and an interdisciplinary team, that’s like, the backbone of good care.”
Going deeper with documentation improves quality of patient care and planning
Jehiah Chalifour, Site Manager at Aberdeen Hospital, addresses the larger implications of electronic health records following patients through the health care system.
“Our documentation will now also work to serve our residents when they present at another Island Health care venue such as the emergency department or a transfer to another LTC home,” says Chalilfour. While papers can rarely tell a patient’s whole story, and in the worst case, can get lost, electronic records provide a more seamless transition between facilities.
“The pertinent information required during transitions in care from our documentation will be readily available to the most responsible clinician even in the new venue,” says Chalifour.
Joyanne Plewes, Site Manager at Glengarry, notes how having all the information in the EHR will help interpret how care is going at the unit level, as well as for individuals.
“It’s one point of access where you can really find out how an entire unit of patients or residents are doing.”
Talking about the “Resident Overview” function, Plewes says, “I can literally pull it up and there are columns: MOSTs and bowel care and antipsychotics and all of that stuff is at a glance as opposed to running down and flipping through the charts.”
Patti Linden, a Clinical Nurse Specialist in PowerChart for Long-term Care, who has supported staff at both Aberdeen and Glengarry, as well as the other LTC go-lives, and standing with Plewes, notes another useful function of the EHR: “The ability to trend things – to graph and trend the date and see which way it’s going.”
Joyanne laughs and says, “I’m not that advanced yet!”
“It’s not that hard”, says Patti, smiling.
“I’ll get there!” says Joyanne.
