EMR leaders, HIM staff offer enhanced problem summary list procedures
By Michele Rainford
APRIL 12, 2007--Through the extraordinary efforts of UTMB Electronic Medical Records system leaders, clinicians, the Health Information Management department and Information Services (IS) personnel, an innovative procedure was developed and implemented to enhance the way UTMB records major diagnoses, procedures, drug allergies and medications for its patients.
The Problem Summary List (PSL), which includes major diagnoses, drug allergies, surgical history and medications, is a part of each patient’s record and is a standard required by The Joint Commission (formerly JCAHO)—the independent, nonprofit organization that sets national standards and provides voluntary accreditation for health care organizations.
The Joint Commission standard requires that each patient receiving continuing ambulatory care services must have an up-to-date Problem Summary List in their medical record. The PSL is a list of the patient’s significant diagnoses, procedures, drug allergies, and medications.
In the past, this information was maintained in different parts of the paper chart and was not always up to date. While some clinics had successfully begun using the EMR to track the PSL information, there was still no single place to look for a reliable Problem Summary List for every patient at UTMB.
After analyzing the requirements and available options, the PSL Team devised a new process that would allow all UTMB clinicians to share a single PSL for each patient. The Epic EMR system would store these problem summary lists, and clinicians would review and update the list each time the patient was seen at UTMB.
In clinics that already use Epic EMR, the process is straightforward. Clinicians update the PSL simply by interacting with the computer system at each visit. For example, when a physician writes a prescription using the EMR system, the prescribed medication is automatically added to the patient’s medication list.
For those clinics not yet using the Epic EMR system, Information Services personnel designed an innovative system that automatically prints a copy of the PSL from Epic when the patient arrives for an office visit. The physician reviews and updates the paper PSL during the patient’s visit. Updated patient forms are picked up at the end of each day by the HIM department and any changes are entered into Epic by a dedicated team.
Senior Director of Hospital Administration, Jennifer Baer, who is responsible for health care quality and patient safety, conducts spot checks to ensure the process is working as it should.
“I am very excited about the results of this initiative,” Baer says. “Not only are we in compliance with The Joint Commission, but I am seeing much more patient information being documented, which can only have a positive impact on patient safety and the quality of patient care. I have also received feedback from a number of physicians—mainly surgeons who rarely had PSL information—who are really pleased to have this information when they see their patients; they feel that it improves patient care.”
Through hard work and dedication, and sometimes working on weekends, IS personnel were able to implement the change in an amazing six weeks.
As each clinic starts using the Epic EMR system, IS simply shuts off the printing process and the clinic seamlessly shifts to direct use of the EMR. No further action is necessary. The information on the previous PSL is already stored in the Epic system to be viewed and updated at patient’s next visit.
The wonderful teamwork that culminated in the successful implementation of this new PSL procedure exemplifies the spirit of cooperation and the dedication of UTMB clinicians and staff.