SYLACAUGA — In November, Coosa Valley Medical Center began utilizing an automated documentation system to move away from paper-based procedures, which hospital officials say will be the standard in medical facilities everywhere."I think it will happen first in hospitals then doctors’ offices," Internist Dr. Bill Friday said.
"The percentages will gradually go up, but the fact that a hospital our size has undertaken this shows how widespread it is."
The system gives physicians and nurses at CVMC access to their patients’ vital signs and medical records with the click of a mouse. The Point-of-Care system is provided by the Mobile-based company Computer Programs and Systems Inc. Hospital officials say the system will help give the right data to the right caregiver through every step of the patient-care process.
The biggest challenge in the crossover will come in May, allowing physicians the capability to not only view a patient’s medical records, but immediately act upon them without ever having to step foot in the hospital.
The Physicians Order Entry component of the electronic Point-of-Care system means doctors will have remote access to review a patient’s chart in real-time. They can check their status and make orders in every aspect of care, such as laboratory tests, X-rays, diet restrictions or prescriptions, all from a Web site, said Friday, who is also the physician liaison for implementing the program.
"From home, for example, if you’re wondering how a patient is doing, you have to call and check and maybe not get all the information if their chart is not complete or a nurse may have trouble (finding out)," Friday said.
When physicians go into the system, they can choose from a standard order for a common diagnosis, such as pneumonia, which is usually treated the same way; or they can choose a customized order mainly used for an uncommon diagnosis like tuberculosis, Friday said.
"Studies show you eliminate a big percentage of error by simply having a physician enter an order — by 80 percent — because a paper (order) can get lost or doesn’t make it to the right department. This way steps are eliminated because it goes electronically to the department." Another plus, he said, is that "it reminds you that this is what you always do for pneumonia. It’s very helpful."
Access to POE ability will reduce the need for telephone and hand-written orders, making services more efficient and eliminating errors from misinterpretation.
"Medical records have changed so much and really made this necessary," Friday said. "It was pretty much kept in short hand, which really only physicians could understand. And, really, if you were not already involved you wouldn’t know what all was going on."
The hospital eased into the transition first by phasing in two other components of the Point-of-Care system in November.
Med Verify, a key tool for nurses, allows personnel to enter information into the CPSI system from a mobile computer work station at a patient’s bedside and review information in real-time.
The system will guide the caregiver through an exam with automated prompts and warn them of potentially harmful drug reactions. An armband with a barcode is scanned to identify if a nurse is assisting the correct patient and can also scan medication to verify that it is given at the right time, said Jeff Wood, Intensive Care Unit and medical floor director of nursing.
Med Verify automates the entire process, making information instantly available to share between physicians and nurses who would otherwise have to wait their turn for a patient’s paper chart.
The other component, Chartlink, also lets physicians access their patients’ information in real-time, but now it doesn’t have to only be done in the hospital. This enables them to look at patients’ charts more regularly, and will work hand-in-hand with the POE system.
Once the POE component gets under way, the hospital will become one step closer to achieving its digitized plan.
"The ultimate goal is to have complete electronic records only accessed through a computer," Friday said. "Right now we’re still on a dual system," and even though costs to implement the system aren’t cheap, hospital officials want to be ready sooner rather than later to "achieve goals it has had all along, and more quickly. We want to be in the lead in taking initiative on that."
