A change in the electronic recordkeeping system at UnityPoint Clinic - Fort Dodge was implemented early this month starting on Aug. 3. Local officials at UnityPoint Health said this modification will benefit both doctors and patients.
Just a few years ago, anyone who visited a doctor's office - or was a patient in a hospital - probably realized that there existed an oftentimes thick document in which what took place was recorded - the medical record.
At Trinity Regional Medical Center and UnityPoint Clinic - Fort Dodge, those hefty paper files are now as obsolete as carbon paper and typewriters. During the last several years, the capabilities of modern computers have transformed health care recordkeeping. Electronic health records have taken the place of bulky paper files.
-Messenger photo by Hans Madsen
Using the new integrated electronic record keeping system, Dr. Michael Willerth is able to show his patients their digital x-rays. With the old system, x-ray images could not be accessed.
Nearly three years ago, electronic records were implemented at TRMC. It pioneered the shift to such records that has now taken place at all hospitals in the UnityPoint Health System. The software used in those hospitals for this recordkeeping purpose is a product called Epic. By the time Epic was introduced in the hospital setting, all the physician offices in what was then Trimark Physicians Group - now UnityPoint Clinic - Fort Dodge - were already using electronic records. They, however, were using different software, called Allscripts.
Pam Halvorson, vice president, clinic operations for UnityPoint Clinic - Fort Dodge, said this month all physician offices in the region have now shifted to a new Epic software product that makes communication between the office and hospital settings seamless.
"The more we keep information in one spot for doctors, for patients, for families that is a good thing," she said.
Dr. Michael Willerth, a surgeon affiliated with TRMC and UnityPoint Clinic - Surgery, has helped the hospital and clinic plan and implement the transition to electronic records. He said the latest change will improve communications between health care providers.
"One of the huge advantages for the doctors is communication between the clinics and the hospitals," he said. "Any of the outlying hospitals can directly communicate now with that same record. Since the rural hospitals came to that product it's just huge for us in the hospital seeing what they've done in their facilities, the work-up that's been done on the patient - the testing, the treatment. Especially if they are transferring that patient here we can see what's been done."
Willerth said the capabilities of the electronic system eliminate many of the delays that traditionally slowed down communication between physicians when care involved consultations and the input of assorted specialists.
"Any note that I create today, my colleagues can go to that chart and view instantaneously," he said. "(In the case of a consultation) a message is sent to their inbox. It's just a matter of them checking their messages to see if there is a message for them."
Willerth said that physicians benefit from having a huge amount of information about the patient at their fingertips.
"The information in the chart is so easy to get now," he said.
Halvorson stressed that having a uniform system both in the clinics and hospitals will help keep the kinds of mistakes that occur due to miscommunication from happening. She said the tracking of medications prescribed is one of the areas that will be improved.
"One of the hardest things to do is what we call medication reconciliation, where the patient has a medication list, the hospital has a medication list, the clinic has a medication list," Halvorson explained. "This is one of the most difficult things across the nation to get in sync. Having one medication list that looks the same when you open up the record allows us to minimize mistakes, omissions from the medication list, duplicate medications that may have been given in one hospital that we didn't know about in the clinic. This becomes very important for patient safety."
Prior to this latest system enhancement, UnityPoint patients already had online access to a significant amount of information about the care they had received. This information, however, was not in one place. Now it is.
"We actually had two different patient portals," Halvorson said. "We had one if you went to Trinity Hospital or a critical access hospital that was on Epic. Then we had another one that was over on the Allscripts side for patients who came to our clinics. If a patient wanted to see what happened in the hospital, they had to go to one. If they wanted so see what happened in the clinic, they had to go to the other. Now these are all merged."
The information available online is extensive. It doesn't include everything that is in the patient's record, but a great deal is accessible.
"They can see their test results," said Emily Peters, who is the site coordinator for implementing Epic in the clinics. "There are some things that they can't see that are sensitive. They can see their vitals, some history. It may not be in-depth, but they can see their history."
The system also enables the patient to communicate with the doctor's office about their care.