By Dr Sreenivasan Narayana
Implementation of digital tools like Electronic Medical Records (EMR) has slowly taken the center stage in healthcare delivery and can be safely assumed as the new normal. It tremendously helps in improving clinical outcomes, as it enables doctors, nurses, and paramedical staff to conduct their daily operations with much ease and efficiency.
As per my observation, a lot of doctors are not well accustomed to using EMR, neither are they keen on learning it. Hence, in our organization we made it easy by making a lot of operational changes, which led to a massive adoption of EMR in the Outpatient (OP) Level.
At the OP level, the user interface is so easy that the data can be entered by devices such as desktop computers, iPad, or even a phone.
To understand how the re-engineering of the whole process helps us improve outcomes, the information is now available at the click of a button, to begin with. All the past and current details of the patients are being managed by the computer. This can be achieved by understanding each aspect of the clinical operations and noting down the changes that must be done from a paper environment to a paperless environment without affecting operational flow.
To execute this in real time, we should first understand the patient movement, the movements of how the caregivers and doctors communicate with each other when they refer a patient from one doctor to another, or when the same doctor needs a senior to re-examine the patient. In addition, how a doctor communicates with the nurse and how the nursing team then engages with other caregivers such as a pharmacist or paramedical person, physiotherapist, and other teams to continue the treatment journey. The other aspect to look at is the IT systems, which ensures that all required interfaces and technical limitations are taken care of and the systems are up to date in terms of delivering capabilities.
Having analyzed all the aspects of this re-imagination of the healthcare delivery, we tried to understand six patient scenarios – ones who seek preventive care, care for sickness, care for emergency, patients with chronic disease who keep coming for periodic care and are already aware of their disease, patients with mitigation top up, and patients who come for follow up.
For example, if a patient who has come to seek preventive care and is extremely worried can just has a minor issue in reality. In such cases we engage with the patient differently than how we engage with a patient who needs serious care. To elaborate this, let’s take an example of oncology care, where a medical oncologist comes across different kinds of patients. One is a new patient who doesn’t know he has cancer, and it comes across as bad news. The other one is a patient who already knows that he has cancer, but he must undergo chemotherapy, so his complete blood count must be done to see if white blood cells are normal. Then, there is another set of patients who come just for follow up to get reassurance because they are on chronic cancer care management.
For each of these patients, the time spent by the doctor is different. For instance, in the appointment management system, the doctor would attend the chemotherapy patients in the first few hours; so that he can assess the CDC level and decide whether these patients can undergo chemotherapy and then put them into the chemotherapy process. The doctor would love to spend more time explaining to the patients what is happening in their body or breaking the bad news to them slowly. Here, the doctor would require one hour for the patient as compared to 15 minutes with other patients. Then comes the last slot for follow-up patients.
The thing to note here is, how we re-engineered the whole appointment system itself using the distinct tools to ensure that there’s a clear way of taking the patient into the system, thereby improving the outcomes.
When it comes to the doctor using the EMR, we have created systems which help improve the patient outcome by different mechanism. One such mechanism is critical lab alert. Our EMR system has a way of identifying already saved critical values. For example, if a doctor receives a notification on SMS, email, or an alert on the EMR system, he knows that the patient he attended this morning in OPD has his values out of the way and he must admit this patient.
With EMR, the doctor gets a critical value alert for the patient, and he can call back the patient informing to get admitted or counseling for further treatment. This happens through critical lab alert admission notifications. The doctor is now able to communicate with IP teams to inform about the patient’s admission and keep things ready for the treatment so that there is no delay in admitting the patient. Everything is being done directly through EMR, even the repository of referral database. Most of the doctors are mobile, some of them are in OP, some are in IP, and some of them are taking some courses or conferences. In such scenarios, EMR helps the doctors know details of the patients referred to them by other doctors. This availability of referral database enhances the clinical outcomes as no patient is missed.
Similarly, the digitization process involves CDSS capabilities. Now, clinical pathways vary where we have drug-to-drug interactions, drug-to-allergy interactions, and drug-to-disease interactions. So, when the doctors prescribe medications now, it helps improve the way of giving medicines to the patients. And if there is any confusion, the doctors can read up more about these things.
Then, we have UpToDate system where the doctors can have literature search on different topics. Also, our doctors can see how much of the inventory is left. For example, the doctor needs a medicine and only 20 of these medicines are available in the pharmacy, he can tell the formulary to stock up more of these medicines because this is something the doctor regularly uses. Let us say there is a medicine which is not available in the formulary in a paper and pen environment.
Neither the doctor would not know that it is available in our pharmacy and the patient could just go and buy it outside; and the pharmacist would not be able to always communicate this back to the doctor. Here with UpToDate, the doctor knows this medicine is not available and they can tell the formulary team to immediately stock these medicines. All these capabilities are possible to re-engineer the operations within the system using the digital process and helping better patient outcomes.
Our EMR is integrated with many devices. We have live monitors, which go on to the EMR and doctors sitting somewhere very far can see what is happening in the ICU. The doctor can also monitor parameters such as a BP, heart rate, echocardiogram, and many other activities virtually. If he needs to change anything, he can communicate that to the caregiver on the other side. Our processes have changed even for chronic disease management and we are now able to give our patients remote care using our devices wherein patients have an app. where they can feed information.
There are educators between doctors and patients who go through all the details and/or queries entered by the patient and then curate it and send it to the doctor. The doctor can then give specific advice and treatment to these patients. In case of any changed values noticed, the doctor can go back to the patient and communicate this. This is a live 24-hour service so that a remote patient is always connected with our doctor internally.
We also have done some changes in clinical operations wherein we are trying to monitor for very specific diseases or departments. Doctors have now given templates that the patient can use at the time of seeking an appointment along with a link for patients to enter all their details, for example, smoking history, alcohol consumption history, family history, and so on. The patients can enter some of these details sitting at home and can then directly meet the doctor for their appointment.
Once the doctor reviews the details entered by the patient and agrees on them, these are entered in the EMR system, which saves the doctors’ time spent on entering all these details. We have done these kinds of initiatives operationally to improve the outcomes because this saves time and decreases the time spent by the patient within the hospital. We also have another system wherein a patient just walks into the hospital and doesn’t have to go through the queue in terms of standing at the reception to collect a token or pay for any investigations.
Everything can be done using the patient’s mobile. He can just walk in directly after taking the appointment, see the doctor, and exit without having to go to any other counter. So, in conclusion, putting patient at the center of every decision making, using digital capabilities to improve content in terms of literature search for doctors and nurses, and using UpToDate or any other decision support tools has reduced a lot of variability and improved outcomes for our patients.
(The author is Group Vice President – Electronic Medical Records Implementation at Narayana Health. The article is for informational purposes only. Please consult health experts and medical professionals before starting any therapy or medication. Views expressed are personal and do not reflect the official position or policy of the Financial Express Online.)