Development of electronic medical record charting for hospital-based transfusion and apheresis medicine services: Early adoption perspectives.
BACKGROUND
Electronic medical records (EMRs) provide universal access to health care information across multidisciplinary lines. In pathology departments, transfusion and apheresis medicine services (TAMS) involved in direct patient care activities produce data and documentation that typically do not enter the EMR. Taking advantage of our institution's initiative for implementation of a paperless medical record, our TAMS division set out to develop an electronic charting (e-charting) strategy within the EMR.


METHODS
A focus group of our hospital's transfusion committee consisting of transfusion medicine specialists, pathologists, residents, nurses, hemapheresis specialists, and information technologists was constituted and charged with the project. The group met periodically to implement e-charting TAMS workflow and produced electronic documents within the EMR (Cerner Millenium) for various service line functions.


RESULTS
The interdisciplinary working group developed and implemented electronic versions of various paper-based clinical documentation used by these services. All electronic notes collectively gather and reside within a unique Transfusion Medicine Folder tab in the EMR, available to staff with access to patient charts. E-charting eliminated illegible handwritten notes, resulted in more consistent clinical documentation among staff, and provided greater realered. However, minor updates and corrections to documents as well as select work re-designs were required for optimal use of e-charting-time review/access of hemotherapy practices. No major impediments to workflow or inefficiencies have been encount by these services.


CONCLUSIONS
Documentation of pathology subspecialty activities such as TAMS can be successfully incorporated into the EMR. E-charting by staff enhances communication and helps promote standardized documentation of patient care within and across service lines. Well-constructed electronic documents in the EMR may also enhance data mining, quality improvement, and biovigilance monitoring activities.
Levy
Rebecca
R
Department of Pathology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA.
Pantanowitz
Liron
L
Cloutier
Darlene
D
Provencher
Jean
J
McGirr
Joan
J
Stebbins
Jennifer
J
Cronin
Suzanne
S
Wherry
Josh
J
Fenton
Joseph
J
Donelan
Eileen
E
Johari
Vandita
V
Andrzejewski
Chester
C
Arch Pathol Lab Med. 2009 Jun;133(6):933-7
19492886
Proc AMIA Symp. 2001;:508-12
11825240
Clin Lab Med. 2007 Dec;27(4):823-43, vii
17950900
J Am Med Inform Assoc. 2002 Sep-Oct;9(5):529-39
12223505
Transfusion. 2012 Nov;52(11):2310-20
23216230
AIDS Read. 2007 Aug;17(8):411-7
17717885
J Clin Apher. 2007 Jun;22(3):106-75
17394188
Jt Comm J Qual Improv. 2001 Oct;27(10):509-21
11593885
Transfus Med Rev. 2007 Jan;21(1):49-57
17174220
Transfusion. 2005 Oct;45(4 Suppl):189S-205S
16181403
J Am Med Inform Assoc. 2008 May-Jun;15(3):383-5
18308991
Immunohematology. 1996;12(2):87-9
15387748