MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. -- From a new triage workflow to standardized order sets to communication shortcuts, the emergency room team at Madigan Army Medical Center is constantly finding new ways to use or improve MHS GENESIS.The section's largest project by far was revamping the triage notes to improve the workflow, add stronger psychology documentation and bolster falls prevention, according to Krista Marcum, a staff emergency room nurse who runs operations for the ER's nursing section and leads performance improvement as well. In total, revising the notes took about nine months of coordinated effort."There was some fine adjusting to it, but I think overall it is much more user-friendly and what we've been able to do is build in more safety features that trigger the physician to be aware of the suicidal patients or the high-risk falls patients," said Marcum.Super User Dana Engness, a registered nurse in the ER, took part in revamping the note as well, to include testing it out before it went live. She said the ER team was able to suggest and help implement practical changes, such as including international traveling in the initial triage screen, and moving items like tobacco usage and medication lists to the second screening that is done in patient rooms.Altogether it took a multiservice and a multidisciplinary team (leadership, physicians, nurses, a psychiatrist and informatics experts) to put together revised notes that affected care from the emergency room to inpatient floors.Marcum offered some lessons learned for others attempting to influence change in MHS GENESIS."What I learned with the triage notes is to know ahead of time that if there's a big fix with (MHS) GENESIS that's going to require high-level people like the architects and the (solution) owners of (MHS) GENESIS, go to them knowing what needs to be fixed specifically and what you need out of it," she said. "Also know who are the key players involved and how they will be affected and make them a part of the team."The ER team's high level of engagement with MHS GENESIS in general can be attributed to the unit's culture of flexibility."You can't really work in the emergency room without being flexible, so when you get a new system, you just figure it out and you learn it," said Marcum.So far, the team has harnessed small wins like using the comment section on their patient tracking board to note status changes such as if standardized order sets are complete or if a patient is at X-ray or ready for a CT scan, for instance. Since other specialties can see the comments as well, the use of this function speeds up communication and patient care -- Marcum said "the comment section has been gold."The tracking board, which pulls data from MHS GENESIS, overall offers the team greater oversight of their patient population from the waiting room to the ER bed or urgent care, offering a finer safety net, she said.Even ER-driven projects such as their early evaluation team, which allows patients in the waiting area to get head starts on orders and labs, improved by taking advantage of the tools in MHS GENESIS."(MHS) GENESIS has played a key role in that because our super user has been able to put in standardized order sets under her shared name. Any nurse can go in there and actually pull up these standardized orders, and we know they're the most accurate order," said Marcum.She's actually working on a Lean Six Sigma project herself to shorten the admission process time from the ER to inpatient floors, and improved communication and MHS GENESIS play key roles in those plans. Likewise, the electronic health record is a part of many of the 16 ongoing performance improvement projects in the ER.In general, the ER encourages a culture of end user engagement; anyone can make a suggestion for an improvement to MHS GENESIS, said Betty Vaughan, a licensed practical nurse in the ER."Collectively, when we do our morning huddles, we do discuss changes that have occurred, or if any of us have suggestions, we make suggestions," she said. "At any point if you come across something, you can immediately go talk to somebody about it or send them an email saying 'I came across this; what can I do about it?' and then it's always addressed."The ER Super Users are easily accessible by email, and will get eyes on an issue if needed to get more information on how to address it, said Vaughan.In fact, she said she believes that their system of communication could work for sections throughout the hospital, encourage regular MHS GENESIS feedback during morning huddles or weekly meetings, allow end users to directly engage with super users to demonstrate what they'd like to improve, and encourage super users to elevate these concerns to the next higher level. She also said she encouraged end users to learn from one another and to remain flexible as they learn more about MHS GENESIS and work to improve it.