Electronic Medical Record

I was surprised at how modern the electronic medical record system at NTUH was.  The computer system is similar to that of UC Davis Medical Center in many ways.  Just from briefly perusing the interface, it reminded me of the Epic system I used in my previous inpatient rotations.  Almost everything is online, including the labs, imaging results, HPI on admission, discharge summary, medication administration record, etc.  Day to day progress notes and nursing notes, however, are still handwritten. In order to follow a patient's hospital course, I had to travel to the nursing stations to look through patient binders, something that I had never done in my previous rotations.  Even though the progress notes were often times difficult to decipher, I realized that handwritten notes are much more concise and to the point.  At UCDMC, the pet peeve of many attending physicians is that progress notes are notoriously lengthy, with too much copying and pasting.  The benefit of making people hand write their notes is that it forces them to focus on the most prevalent points.

The medication administration process is also reminiscent of UCDMC: doctors order prescriptions online, the pharmacy fills it, it gets verified by a pharmacist, and the medications are sent to the wards on carts.  Dispensing, on the other hand, is quite different.  All oral medications are provided in unit-dose packages.  Liquid medications are bottled by an automated machine and parenteral medications are dispensed in their original packaging.  All pharmacy interventions are documented in the computer system.  I was unable to obtain permission to post a screenshot of the home screen, so I will do my best to describe it in words.  I mentioned in a previous post that reading Chinese characters would be a challenge for me.  Most of the links and tabs are in Chinese.  I took this as an opportunity to compile a list of medical terminology, which I will include in my next post.  The interface is split up into three sections.  The top 1/3 is the banner, where the patient information and the most current labs are displayed.  The middle 1/3 consists of tabs which serve as quick links to various reports including labs, cultures, pathology, imaging, discharge planning, MAR, diagnoses, inpatient medications, outpatient medications, etc.  The bottom 1/3 contains a list of the active medications the patient is on, along with both brand and generic name, dose, route, and schedule.  Under the generic name of certain medications, there is an icon, indicating that dose adjustment algorithms are available for that particular drug.  The algorithm can be viewed by simply clicking on the icon.  I found this to be a very helpful function.

My preceptor noted that NTUH is moving in the direction of acquiring a point of care dispensing system, similar to a Pyxis machine, to automate the dispensing process and allow pharmacists to focus more on the clinical aspect of their work.  In addition, there are plans to upgrade the software system to allow direct communication between pharmacy and the health care professionals on the wards.  Currently, even though doctors can place orders electronically, communication from pharmacy to the wards is strictly done by phone.

View from the UDD (10th floor of the new hospital building)