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| Resources > Newsletters > Electronic Medical Records (EMR) at Genesis |
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| Electronic Medical Records: A Matter of Safety |
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| Physicians who care for patients with infertility do so with all eyes focused on maximizing the chance of pregnancy. But there is one aspect of patient care that is even more important. It is, of course, patient safety. Primum non nocere – first, do no harm – was rightly taught to all of us during our first days of medical school because it is the principle that supercedes all others. We at Genesis believe, and others increasingly agree, that electronic recording all of all patient medical data is fundamental to patient safety*. As we celebrate our tenth anniversary of using computerized medical records, we share with you the ways in which it assists us in providing optimum quality of care for our mutual patients. |
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| At Genesis, an electronic medical record is created for every new patient, linking all information about her with that of her spouse or significant other, as appropriate. The complete medical history, as well as the physical exam, physician assessment and treatment plans are all documented electronically. Throughout care, all laboratory test results are automatically downloaded to the file. Patient messages and staff responses are routed through an email function that is woven into the program, and hence a record of every phone contact is maintained. Each aspect of treatment is recorded in a separate subfile, or tab, which organizes treatment plans, surgical procedures, counseling notes and nursing instructions. Because our focus is so centered on treatment cycle management, special functions and links are geared to gathering daily data and presenting it to the clinicians for assessment. Earlier this year, for example, we added bar coding to every tube of blood sent for hormonal assay, a feature that eliminates any chance for inaccurate charting of results. While referring physicians may find the printed versions of these patient charts difficult to interpret, in real time the electronic record provides every clinical staff member at Genesis with precise and always legible information. |
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| * Wright AA, Katz IT. Bar Coding for Patient Safety. NEJM 353:329, 2005. |
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| Availability of accurate clinical information is key to assuring patient safety. At Genesis, 200-250 patient contacts occur each day, including visits and phone calls, every one of which requires prompt and accurate management. Fortunately, this does not depend on finding and pulling physical charts, a process which can be grindingly slow. Nor must any staff member ever struggle to decipher handwriting. With each patient visit or call, any clinical staff member can pull up the electronic chart, understand the underlying care issues, and formulate an appropriate response. The ready availability of charts on the computer network also fosters immediate and thorough documentation. We value the role that the clinical team plays in keeping patients connected with our practice; by easing the process by which all of us do our jobs, we have the time to keep every patient psychically and emotionally comfortable during her treatment cycles. The electronic record is, therefore, part of the ingredient behind the personalized attention that distinguishes care at Genesis. (The best people, of course, being the major part.) |
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| Perhaps the most common way that the electronic record protects patient safety is in its 24-hour accessibility. As every practitioner knows, patient calls do not cease when the office closes. But when a Genesis patient calls at an odd hour of the night or weekend, her chart is never far away. All patient information can be accessed via a secure, remote connection. It is not uncommon for a Genesis physician to review a caller’s records from home in order to arrive at the proper clinical management decision. |
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| In 2000, the Institute of Medicine published a now-famous report entitled To Err Is Human. This report documented the frequency with which medical errors harmed patients. In response, many hospitals have adopted computer-based systems that prevent the calculation and translational errors that are the source of many such errors. At Genesis, we celebrate a decade of experience in using the electronic record successfully in the care of many thousands of patients. We are proud that our record of success is matched equally by our record of safety. |
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| October 2005 |
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