Acute Care Physical Therapy and Occupational Therapy Involvement throughout Implementation of a Hospital Electronic Health Record

Abstract

Purpose: To describe processes, opportunities and challenges encountered by an acute care rehabilitation department during electronic medical record (EMR) implementation. The EMR can enhance quality, safety and efficiency but hospital adoption has been slow. Due to widespread support and financial incentives, implementation of certain areas of the EMR, such as medication administration and order entry, has become more prevalent. Methods: During the design phase of EMR implementation, rehabilitation managers participated in several committees including system development and hospital infrastructure hardware assessment. For rehabilitation staff, EMR education was multimodal utilizing a train-the-trainer approach, including computer-based training, face-to-face, and classroom education. Due to resource constraints, the Information Technology department provided limited support to build and implement rehabilitation EMR documentation. The rehabilitation department took the initiative to internally develop and implement electronic documentation utilizing tools offered within EMR software. Results: Average visits temporarily declined by 13.7% for PT and 8.4% for OT during EMR implementation; the volume of treatments returned to previous numbers after implementation. EMR implementation decreased the need for aide staff to spend time and resources to support the paper medical record. Conclusion: EMR committees offered a direct line to provide input and troubleshoot EMR issues and increased awareness of options and processes. This empowered the rehabilitation department to seek creative ways to develop electronic documentation.