Clear and Concise: EMR Technology Helps Nurses and Staff, Too

By Tiffany Rodstrom, RN, Cleveland Clinic Cole Eye Institute

Tiffany Rodstrom, RN, a 5-year veteran of Cleveland Clinic’s Cole Eye Institute who works primarily with a retina specialist, uses the institute’s electronic medical record (EMR) system in virtually every facet of her job. She says it particularly reduces problems with unclear plans from previous patient visits.

“Prior to EMR, it was difficult to tell what tests the doctor wanted performed on the next visit,” Rodstrom says. “EMR has helped tremendously in this regard because the future visit plans are concise and easy to understand.” It also improves communication between the providers and their secretaries, surgical schedulers, referring physicians and other departments.

Initial staff wariness eases

Although some staff members were initially wary of the changeover, she says most like it now. Rodstrom had been through another EMR implementation, and at Cole Eye Institute she worked closely with the information technology team as the system was developed. “With my previous role as a certified ophthalmic technician and now as a nurse, I used my knowledge to help customize our EMR system and streamline our patient exams,” she says.

One of Rodstrom’s favorite features is the ability to add ophthalmic drawings, previously done by hand, into the EMR. “We added stencils that annotate the drawing and put information into the exam,” saving the physician steps. “The drawings are improved, allowing for clearer communication about our findings,” she says.

EMR essential for handling patient loads

Prior to EMR, it was difficult to tell what tests the doctor wanted performed on the next visit. EMR has helped tremendously in this regard because the future visit plans are concise and easy to understand.

Rodstrom finds that the EMR system boosts efficiency in Cole Eye Institute’s busiest services. Some specialists see 70 or more patients a day, about half of whom need some form of diagnostic testing. Moving them all through and documenting their exams, procedures and diagnostic interpretations is crucial.

The EMR system’s “Study Review” module, a feature that tracks all procedures and diagnostic tests a patient undergoes, is helpful, she say. “We’ve added buttons for documentation of exams and procedures, vs. traditional manual entry, which increases our ability to document in a clear, compliant and concise fashion. As part of this, we created 104 custom smart forms and 180 order sets to help us make our workflow efficient.”

Rodstrom says she uses the EMR system in all aspects of her work: rooming patients, phone encounters, care issues and documentation of instructions. Although scribes are not part of Cole Eye Institute’s overall approach to EMR, Rodstrom occasionally fills that role too in the course of her daily work.

Utilizing the EMR system has made patient handoffs to other technicians or doctors much easier, Rodstrom says, thereby improving the overall patient experience.