Explore practical and evidence-based strategies to enhance the use of electronic health records (EHRs) in the perioperative environment.
This APA-formatted paper discusses workflow improvements, staff training, data accuracy, and patient safety benefits.
Solution
Strategies to Optimize the Use of Electronic Health Records in the Perioperative Setting
Introduction
The perioperative
environment, including preoperative, intraoperative, and postoperative
environments, is a high-risk area where effective information flow is essential.
Electronic Health Records (EHRs) offer an organized process of gathering and
disseminating information, which promotes safe surgical care. Despite their
potential, EHRs can present workflow challenges and usability issues if not
implemented effectively. This article discusses methods of streamlining the use
of EHRs in the perioperative environment, such as educating personnel, workflow
incorporation, decision-making aids, enhancement of interoperability, and
ongoing review.
Comprehensive Staff Training and Engagement
The main planning idea is
the thorough training based on the specifics of the work of perioperative
personnel. Each member of the surgical team who interacts with EHRs will have
their own modes of interaction. Simulation-based training reduces stress and
improves readiness to use EHR in real-time under the pressure of time (Nuamah
et al., 2022). It involves engaging users in the process of developing and
refining the EHR tools, which will create a certain sense of ownership, as well
as allow attuning the system to the actual clinical needs (Classen et al., 2023).
User acceptance and satisfaction may be increased by gathering frequent
feedback and engaging clinical champions, employees who promote the system and
assist in their role as mentors to others.
Workflow Integration and Customization
The integration of EHRs
into the perioperative workflows should not be disruptive, as it may contribute
to a higher cognitive load and documentation time. Clinicians can document
faster and more reliably by customizing the templates, smart forms, and
checklists involved in surgery procedures and specialties (Wu et al., 2024). As
an example, it is possible to incorporate the preoperative checklist and
surgical safety protocols into the EHR to guarantee that they are not only
followed routinely but also readily available during the surgery.
Streamlining the sequence
and timing of EHR-related tasks would reduce redundancy and time wastage, like
any automation of lab results submitted previously to a planned operation or
alignment of documentation among various providers. Instituting tools of voice
recognition or touchless documentation in a sterile area will enhance the
applicability and enable real-time data access without interrupting surgical
activities.
Clinical Decision Support and Alerts
EHRs have Clinical
Decision Support Systems (CDSS) that can give directions to the providers
through alerts about problems, such as medication errors or the lack of safety
measures performed. To illustrate, through alerts, it is feasible to administer
prophylactic antibiotics in time (Nanji et al., 2021). However, excessive
alerts may lead to alert fatigue. Customizing alerts for clinical relevance and
engaging the providers in the development of alerts contributes to the
usefulness of alerts without overload.
Enhancing Interoperability and Data Sharing
Effective perioperative
communication with other departments, including surgery, anesthesia, radiology,
and post-anesthesia care, is also critical. Efficient use of interoperability
of EHR allows various systems to exchange and process data in an understandable
manner, enhancing the process of care coordination and minimizing duplicate
testing (Sreenivasan & Chacko, 2021). As an example, a unification of the
anesthesia records with the surgical schedule and the postoperative recovery
records ensures continuity of care that might disrupt patient safety.
Preoperative assessments
may also be improved by using Health Information Exchanges (HIEs), which can
give access to the previous surgical history of the patient, previous
laboratory results, medications, etc. Within this comprehensive picture of the
patient, it is possible to be more complete when estimating risk and planning
the surgery.
Monitoring Outcomes and Continuous Improvement
Lastly, one of the most
important approaches towards the optimization of EHR usage is providing the
means of ongoing control and quality adjustment. Actionable insights may be
offered by performance dashboards, tracking such metrics as documentation completeness,
time to first incision, and adherence with safety checklists (Blijleven et al.,
2022). These analytics tools can be used to identify bottlenecks, to support audits,
and to inform reviews of policy.
Conclusion
EHR optimization in the
perioperative environment entails harmonized initiatives such as staff
education, workflow integration, clinical decision support, interoperability,
and assessment. When implemented effectively, these approaches enhance
documentation efficiency, improve communication, and ultimately contribute to
safer, higher-quality surgical care in the digital era.
References
Blijleven, V., Hoxha, F., & Jaspers, M. (2022).
Workarounds in electronic health record systems and the revised sociotechnical
electronic health record workaround analysis framework: Scoping review. Journal
of medical Internet research, 24(3), e33046. https://doi.org/10.2196/33046
Classen, D. C., Longhurst, C. A., Davis, T., Milstein, J.
A., & Bates, D. W. (2023). Inpatient EHR user experience and hospital EHR
safety performance. JAMA Network Open, 6(9),
e2333152-e2333152. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2809149#249219862
Nanji, K. C., Garabedian, P. M., Shaikh, S. D., Langlieb, M.
E., Boxwala, A., Gordon, W. J., & Bates, D. W. (2021). Development of a
perioperative medication-related clinical decision support tool to prevent
medication errors: an analysis of user feedback. Applied Clinical
Informatics, 12(05), 984-995. https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0041-1736339#info
Nuamah, J. K., Adapa, K., & Mazur, L. M. (2022). State
of the evidence on simulation-based electronic health records training: A
scoping review. Health Informatics Journal, 28(3),
14604582221113439. https://doi.org/10.1177/14604582221113439
Sreenivasan, M., & Chacko, A. M. (2021).
Interoperability issues in EHR systems: Research directions. Data
analytics in biomedical engineering and healthcare, 13-28. https://doi.org/10.1016/B978-0-12-819314-3.00002-1
Wu, J., Yuan, C. T., Moyal-Smith, R., Wick, E. C., &
Rosen, M. A. (2024). Electronic health record-supported implementation of an
evidence-based pathway for perioperative surgical care. Journal of the
American Medical Informatics Association, 31(3), 591-599. https://doi.org/10.1093/jamia/ocad237