The emergency departments in Saskatoon are one step closer to an electronic health record.

Electronic charting is coming to the Royal University Hospital Emergency Department (ED) this year; an important step in preparing for the ED’s move into their new space within  the Children’s Hospital of Saskatchewan.

Three people demonstrate the electronic documentation system

Allscripts (SCM) software resource Sherry Wright (left), RUH RN Jason Shand, and eHealth business analyst Kathy Sadler demonstrate the new electronic clinical documentation system that is coming to emergency departments in Saskatoon starting this year.

The Region began its journey towards an electronic health record in 2012 with the implementation of the Sunrise Clinical Manager (SCM) system. Emergency departments in Saskatoon have led the way with their use of SCM as an electronic triage system and a visual communication tool with an electronic status board and the ability to view patient visit history, regional lab results, radiology results and all documents dictated through regional transcription services.  Introducing electronic clinical documentation to the department is a natural progression.

The goal of this work is to measurably improve patient safety and outcomes, enhance care provider decision-making and workflow, and facilitate the integration and delivery of patient care.

SCM will be used by nurses and physicians in the ED to document clinical information, reducing reliance on paper charts. These electronic documents will contain all patient care information, and will allow the entire care team to access it in a timely manner. More importantly, once documented, the information is always available, eliminating the need for patients to repeat themselves at multiple points in their care journey.

An interprofessional team worked collaboratively for three months to design the new electronic documents and their work culminated in a “Day in the Life” presentation on December 9, 2014. Clinical scenarios were used to show how the information will flow from one health care professional to another, and to give staff a sense of what it will be like to work with electronic clinical documentation.

“This tool is going to serve you, it is going to make your life better” said Jason Shand, a registered nurse in the RUH ED and a member of the design team who helped lead the demonstration.

Right now, there’s a time delay when accessing paper patient records. When SCM goes live, as soon as a patient sits in a triage chair, caregivers will be able to see their past medical history. These electronic documents will also be more thorough and easier to understand than paper documents, as everything will be typed.

“It will take away that handwriting variance,” Shand noted.

A large number of staff have been involved with building the system since the design process began in September.

“It’s designed by clinicians, for clinicians,” said Kathy Sadler, a member of the development team.

The system gives caregivers the ability to harness information that’s legible, timely, and accessible from anywhere in the department, Sadler explained.

“A lot of clinicians have to rely on their memories when dealing with patients, or information from the patient which may or may not be completely accurate,” said Sadler. “Or they have to wait for paper files to arrive before determining a course of action. This system will give clinicians something to refer to right away, which improves the situation for the patient, as all of their health details are right there, including past diagnoses. To have an actual diagnosis instead of vague information provided by the patient can change how clinicians care for someone.”

With SCM, caregivers won’t have to start from scratch every time they see a patient, Sadler added. They’ll be building on previous information.

This new system will replace almost all papers in the emergency room – nursing assessments, progress notes, vital signs and physician assessments.

“The future state we’ve been going towards, we can finally see it on the horizon,” said Shand.

Staff will be supported along that learning curve. The presentation of the future state design was a preliminary step; official training with the system is scheduled to begin in February.

The initial plan is to roll out clinical documentation in phases, first to the emergency department’s physician and nurses at RUH, Saskatoon City Hospital, and St. Paul’s Hospital, and then to other professions and units in those hospitals, so eventually the largest hospitals in the Region will be as paperless as possible. Rollout to rural facilities will be considered farther into the future.

Questions or comments can be directed to the team at infoflowcommunication@saskatoonhealthregion.ca.