First hospital in Canada with completely paperless medical record system

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Advancing care for people with a mental illness is paramount for Ontario Shores Centre for Mental Health Sciences (Ontario Shores). Having just received the prestigious HIMSS EMRAM Stage 7 award for its completely electronic medical record system, Ontario Shores uses this system to support key decision making for increased quality of care and patient safety.

Ontario Shores is the first hospital in Canada and the first mental health hospital in the world to receive this recognition. Awarded to healthcare organizations, this designation is given for having an electronic health information system which advances the use of patient data to ultimately improve process and performance.

Having a completely paperless system reduces errors of omission and ensures the care being offered is supported by evidence based standards.

“Our electronic medical record system improves the delivery and quality of care that we provide and standardizes clinical documentation in an environment which is efficient, secure and collaborative,” says Karim Mamdani, President and CEO at Ontario Shores.

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The Stage 7 designation means that patient information documented allows for best outcomes at all times. At Ontario Shores, an electronic assessment is completed when a person is admitted at the hospital.  Within the assessment, there are certain mandatory fields which must be completed and will then guide treatment.  For example, if the person being assessed has a history of smoking, when the documentation is completed, the system will automatically populate with next steps which may include the recommendation of appropriate nicotine replacement therapy.

Similarly, if a physician identifies that a person will be receiving antipsychotic medication in their documentation, the system will automatically populate with a recommendation to closely monitor for potential metabolic side effects. One of the challenges in mental health is that antipsychotic medication may result in increased weight gain, obesity and an increased risk for diabetes.  It is important that these medications when prescribed are accompanied by the appropriate monitoring.  An electronic record system means that once this medication is ordered by the physician, the system automatically generates suggestions for such additional monitoring.  This greatly reduces any errors which may occur and enables clinical teams to proactively address any arising issues and prevent metabolic complications.  ‎

“Since this system of monitoring has been instituted at Ontario Shores, adherence with the ideal recommended metabolic protocols have doubled,” indicates Dr. Ilan Fischler, Geriatric Psychiatrist and Medical Director, Clinical Informatics.

The electronic system also facilitates the sharing of clinical information in a manner that supports the use of patient data to improve performance and transform clinical practices to one which is evidenced-based, ensuring that patients and families are recipients of recovery-oriented care. For example, Stage 7 at work reflects the use of clinical practice guidelines within the organization.  The clinical practice guidelines developed for Schizophrenia and currently being developed for major depression allows staff to use structured templates based on evidence-based practices and the data collected from the system to inform practice and ultimately achieve quality outcomes.

“Having electronic medical records also mean that we can develop clinical scorecards. These are issued to each clinician monthly to determine their adherence to best practices as compared to their peers,” adds Fischler.

One key patient safety and quality of care strategy used at Ontario Shores is the use of computerized physician order entries, where prescribed medication is entered electronically replacing a physician’s handwritten note thus significantly reducing the risk for errors. This is also very significant in identifying any significant drug interactions or allergies the person may have.  Once again, this results in reduced risk and increased safety in patient care.

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Offered by the Healthcare Information and Management Systems Society (HIMSS), the Stage 7 award signifies attainment of the highest level on the Electronic Medical Records Adoption Model (EMRAM). It scores hospitals in the HIMSS Analytics Database on their progress in completing 8 stages (0-7), with the goal of reaching Stage 7 – the pinnacle of an environment which is truly paperless.

“Ontario Shores is truly a leader in their field in the use of electronic health records,” says John P. Hoyt, FACHE, FHIMSS, Executive Vice President, HIMSS Analytics.