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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
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Nursing Clinical Information System (NCIS)
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Improving IV Insulin Administration in a Community Hospital
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Changing patient care orders from paper to computerized provider order entry-based process.

Jane M Brokel1, Marcia M Ward, Douglas S Wakefield

  • 1The University of Iowa-College of Nursing, Iowa City, IA 52242, USA. jane-brokel@uiowa.edu

Computers, Informatics, Nursing : CIN
|April 3, 2012
PubMed
Summary

Electronic Health Record (EHR) order sets evolved significantly over five years in a rural hospital. Physician adoption exceeded 70%, with medication orders comprising 50% of all orders five years post-implementation.

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Area of Science:

  • Health Informatics
  • Clinical Workflow Optimization
  • Rural Healthcare Delivery

Background:

  • The implementation of Electronic Health Records (EHR) significantly impacts clinical workflows and patient care order management in healthcare facilities.
  • Understanding the evolution of order sets post-EHR adoption is crucial for optimizing their use and ensuring provider buy-in, especially in rural settings.

Purpose of the Study:

  • To describe the changes in patient care order sets for six key diagnoses/procedures in a Midwestern rural referral hospital following EHR implementation.
  • To analyze the evolution and utilization of these order sets over a five-year period post-implementation.

Main Methods:

  • A descriptive study analyzing changes in service-specific order sets for conditions including chest pain with acute myocardial infarction, osteoarthritis with hip/knee replacement, coronary artery bypass graft, congestive heart failure, and pneumonia.
  • Data abstraction of order sets at pre-EHR, post-EHR, one year, and five years after EHR implementation.
  • Examination of the growth in order set complexity and physician adoption rates.

Main Results:

  • Order sets evolved with nested structures to facilitate Computerized Provider Order Entry (CPOE), achieving over 70% physician adoption.
  • The total number of patient care orders within sets increased, driven by linked nested orders for medications and diagnostic tests.
  • Five years post-implementation, medication orders constituted 50% of all orders within the analyzed sets.

Conclusions:

  • EHR order sets demonstrated significant evolution, increasing in complexity and adoption by physicians in a rural hospital setting.
  • The findings highlight the importance of deploying and refining order sets within smaller critical-access hospitals to train providers and ensure successful adoption.
  • Continued analysis of order set utilization is essential for ongoing optimization of EHR systems in diverse healthcare environments.