MEDICAL RECORDS Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical Administration ) 1.Medical Records Department 2.Electronic medical records (EMR) 3.Ethics

MEDICAL RECORDS

Dr Kithsiri EdirisingheMBBS , MSc, MD ( Medical Administration )

1. Medical Records Department2. Electronic medical records (EMR)3. Ethics in EMR

INTRODUCTION

• 1000 bedded general Hospital.• For the management and systematic maintenance of

Medical Records in the Hospital a Medical Record Department is an essential component. m

• Staff Medical Record Officer Medical Record Technicians Medical Record Clerks Medical Record Attendants

• The Reception, Enquiry and Admission office functions round the clock under the charge of Medical Record Officer.

• Inpatients records and out patients records are maintained in the Medical Record Department.

• Registration work of OPDs are also managed by the Medical Record Officer.

• Statistical information about the functioning of OPDs is regularly submitted by the Medical Record Officials in the Medical Record Deptt.

Description

DEFINITIONOF MEDICAL RECORD

• Medical Record of the patient stores the knowledge concerning the patient and care given .

• It contains sufficient data written in sequence of occurrence of events to justify the diagnosis, treatment and outcome.

• In the modern age, Medical Record has its utility and usefulness and is a very broad based indicator of patients care.

PatientsDoctorsHospitalTeachersStudentsFor research workNational & International agencies

Benefits of the MRD

ORIGIN :-

• The inpatient Medical Record in originated at the admission office based on the admission order made by the clinician or at Casualty Deptt. and various OPDs of the Hospital.

• Outpatient medical records originates from the registration desk of the OPD and clinic services

Process flow of Medical Records

Central Admission Office Wards

Medical Record Department

1. Assembling

2. ADMN. &

Discharge analysis

3. Storage Area

Afetr completion of Reccords

Hospital statistics prepared Monthly/Yearly

Medical Record is filled for perusal of Patients/claims/research purposes.

OPD and Clinic registration department

FILING OF MEDICAL RECORDS

• The inpatients Medical Record is filed by the serial numbers assigned at central Admitting Office.

• The Record is bound in bundles 100 each and are kept year wise according to the serial number

• OPD and clinic services are also filed in seriol numbers

• Other services too are registered , preventive , investigative and curative care

RETENTION OF MEDICAL RECORD

• The policy is to keep indoor patient Records for 10 years

• The OPD registers for 5 years• The record which is register for legal purposes

in Maintained for 10 years or till final decision at the court of Law.

OUTPATIENT DEPARTMENT

• There is a decentralized system for registration of OPD patients.

• Patients are registered at different registration counter specialty wise.

• Clerks posted for registration have been made responsible for the preparation and submission of statistical data of their respective OPD

FUNCTIONS OF MEDICAL RECORD DEPARTMENT

1. Daily receipt of case sheets pertaining to discharge, 2 A.M.

an expired patients from various wards, there checking and

assembly.

2. Daily compilation of Hospital census report.

3. Maintains & retrieval of records for patient care and

research study.

4. Completion and Procession of Hospital statistics and

preparation on different periodical reports on morbidity

and mortality.

5. Online registration of vital events of Birth & Death

FUNCTIONS OF MEDICAL RECORD DEPARTMENT

6. Issuing Birth & Death certificated upto one year.7. Dealing with Medico Legal records and attending

the courts on summary.8. Arrangement & Supervision of enquiry and

admission office.9. Arrangement & Supervision of OPD registration10. Management of disability boards.11. Management of Medical Examination12. Management of Mortality Review Committee

Meetings (Twice month)13. Assistance to Hospital Administration in various

matters.

SYSTEM OF COLLECTION, COMPILATION AND FORWARDING STATISTICAL REPORTS

• Medical Record officials posted for registration of OPD patients have been made responsible for the preparation and submission of statistical data on their OPDs.

• One Medical Record Officer visits to the wards daily and collects the disease wise reports of the discharged patients and submits the same in the medical record section. One official of the Medical Record Section classifies the data according to the different performa. Following reports are compiled forwarded to various departments.

1. National list for Tabulation of Morbidity and Mortality (IMMR)2. Monthly Health Bulletin3. Monthly report of Polio Cases4. Monthly report of GWEP5. Report of cataract operations6. Report on the notifiable disease 7. Monthly report of communicable diseases8. Monthly report of MNT (Paed & Gynae)

10. Monthly report of AIDS cases11. Monthly report of Anti Rabic cases12. Monthly report of STD13. Monthly report of cases & Death due to snakebite.14. Monthly report of Sex Ratio (Birth Death)15. Monthly report of Malaria cases.16. Monthly report of Deliveries17. Monthly report of Family Planning18. Monthly report of Medicine, DRT, Polio, TT19. Monthly report of Leprosy cases20. Weekly report of Polio21. Weekly report – Statement showing the no. of cases treated (OIVS)22. Weekly report of National Programme for surveillance of communicable

disease (DHO)23. Weekly report of Dengue fever cases24. Weekly report of Pyogenic Meningitis25. Weekly report of Gastro-enteritis, Cholera26. Daily report of Noticeable Disease under surveillance.

3. EMR

Electronic Medical RecordsV 05

EMR

• Making all records electronic by using ICT– Accessibility – Coverage – Efficiency – Effectiveness – Affordability– Sustainability

EMR• Hospital

– Cost effective service – Efficiency – Safety – Confidentiality – Storing and Retrieval and

• Consumer– Convenience – Comfort – Confidence – V 06

Electronic Medical Records (EMRs)

Copyright Claudia Tessier LLC, Boston MA 2009

Topics

• Benefits and functions of EMRs• Criteria for selecting and implementing an

office EMR• ePrescribing: Standalone or Ambulatory

EMR

EMR vs EHR vs CCR

• EMR: electronic medical record– An electronic medical record for a patient at a particular

site, providing such functionalities as e-prescribing, order/results management, work-flow tasking, communication and messaging

– An EMR is NOT a paper record made electronic

• EHR: electronic health record– The sum of a patient’s EMRs and other health- related

information from multiple sites

• CCR: Continuity of Care Record– Electronic core data set about a patient’s health-

care status and treatment, current and historical

What is Pushing You toward EMRs?

• Patient safety?• Quality improvement?• Rising healthcare costs? • Competitiveness?• Consumer-driven care (participatory health)?

– Internet resources– Personal health records

• Evolution not only toward electronic medical record but also to computer-guided and -supported healthcare

What Can You Gain from EMRs?

• More timely, accurate, complete patient information– No longer practicing blindly– Point of care access to,

capture of, transmission of patient information

– Real-time, remote access

• Improved patient care• Improved patient

safety• Improved outcomes

• Reduced costs of healthcare– Reduced wasteful

duplication– Improved efficiency– Financial squeeze on

physicians

• Reduced hassles• Improved quality of

life– For yourselves– For patients

Critical Success Factors

• Office workflow: Who does what, how, when, where, why?

• Current practice management system?• Information capture preferences?• Staffing: Adequate? Ready?• Colleagues: Supportive? Ready?• Financial planning and expectations

– Benefits: Hard, Soft, Stretch• Realistic timeline• What do you want/need from an EMR?• What features do you want?• What barriers do you face?

Increased revenues• Improved reimbursement• Increased patient volume• Increased charge capture• Decreased accounts receivable

days• Increased net collection rate• Decreased denied claims• Improved E&M compliance• New business opportunities,

clinical trials, data• Improved competitiveness

Improved quality of careImproved patient

satisfaction

Decreased costs• Reduced chart filing costs• Reduced transcription costs• Decreased telephone calls,

faxes from pharmacy• Increased efficiencies,

decreased hassles

Improved quality of life• Improved provider satisfaction• Improved staff satisfaction• Less time after hours

What Outcomes Are You Seeking?

What Features Do You Want?• Clinical

documentation– Options– Management– Scanning– CCR

• Clinical and administrative workflow tasking

• ePrescribing– Drug interaction– Formulary mgmt– Refills

• Referrals• Order entry• Results management

– Abnormals– Trends/graphs

• Summary lists– Problems– Allergies– Medications

• Health maintenance reminders

What Features Do You Want?• Charge capture &

coding– Medical necessity– Automated coding– E&M coding &

compliance

• Decision support• Clinical practice

guidelines

• Practice messaging– Internal– External

• Population/disease management

• Patient portals• Patient data entry• Participatory health

What Barriers Do You Face?

• Expense• Selection difficulties• Staff resistance• Time & effort required• Incompatibility of

hardware/software• Ease of use• Security• Lack of technical

expertise

• Obsolescence• Ease of integration• Concerns about ROI• Solutions not right for

you• Lack of demonstration

site• Data/chart conversion• Increase documentation• Other?

What Do You Want to Achieve?

When you are ready to look at systems

When you are ready to look at systems

What do you want to achieve?

1. More money/savings/ROI

2. Better competitiveness

3. Remote working

4. Workflow benefits

5. Better decision support

6. Easier reporting

7. Better information about patients

8. Improved quality of care

1. More money/savings/ROI

2. Better competitiveness

3. Remote working

4. Workflow benefits

5. Better decision support

6. Easier reporting

7. Better information about patients

8. Improved quality of care

1. More money/savings/ROI2. Better competitiveness3. Remote working4. Workflow benefits5. Better decision support6. Easier reporting7. Better information about

patients8. Improved quality of care

1. More money/savings/ROI2. Better competitiveness3. Remote working4. Workflow benefits5. Better decision support6. Easier reporting7. Better information about

patients8. Improved quality of care

Savings from Transcription

Patient Information

Capture

System Efficiency

Better Coding(not guaranteed)

Back-end Speech

Recognition

Front-end Speech

Recognition

Speech Recognition

• Automated coding

• Higher revenues from ‘lost’ charges and better coding

• Success varies

What Do You Want To Achieve?

1. More money/savings/ROI2. Better competitiveness3. Remote working4. Workflow benefits5. Better decision support6. Easier reporting7. Better information about patients8. Improved quality of care


Connectivity with Medical Community

Patient satisfaction

• Referrals• Reports• Labs• Hospital Communication• CCR

• Referrals• Reports• Labs• Hospital Communication• CCR

• Communication by email• Refills• Trust• Efficiency/convenience• Less waiting time• Technology attraction• Computer-generated

patient education• Guidance to websites• Web portals

• Communication by email• Refills• Trust• Efficiency/convenience• Less waiting time• Technology attraction• Computer-generated

patient education• Guidance to websites• Web portals




Remote Computing and Remote Documentation

• Working at home or anywhere

• Arranging your time accordingly




Workflow Benefits

• No waiting or searching for charts (for example, think of phone calls)

• Easier refills• Easier results management • Signatures• Immediate availability of patient

data• Point-of-care documentation• Better time management




Computer and Internet Support for Decision Making

• Formularies• Diagnostic information• Information about medications• Other decision support info




• Query system by condition or medication

• Follow-up and reminders

• Standard reports

• Ad hoc and other reports

ReportsReports




• Receive patient information electronically

• Integrate and create CCR

• All insurance information

• Health status from other providers

Patient InformationPatient Information




• Health maintenance

• Disease monitoring

• Practice guidelines

• Patient education

• Lab tables/interfaces

• Data!!!

Improved Quality of CareImproved Quality of Care


How Can You Use EMRs for Quality Improvement?

• Templates with guideline prompts• Flow sheets, tables, summaries, etc. as decision

aids• Internal messaging and flags for coordination,

self-reminders, goal prompts• Personalized results letters or handouts for

patient education• Lab interface for results reporting• Advance scheduling for followup• Queries to identify patients needing specific care

leading to flags or outreach

How Can You Use EMRs for Quality Improvement?

• Develop effective team communication• Measure for improvement and

accountability• Incorporate performance and outcome data• Coordinate care and services across settings

What Should You Do?

• Educate yourself and others on EMRs– Conferences, web, colleagues, experts, etc.

• Prioritize goals and problems to solve– Narrow potential vendors: Determine

• Cost• Features and functions• Usability

• Set-up vendor demos– Include physicians, staff– Develop scenarios– Site visits to similar practices

How Can You Compare EMRs?

• Practice size designed for, installed in?• IHN/hospital linked?• ASP-based?• Is system designed for and installed in

endocrinology practices?• Costs?• Functionalities?• Usability?

Comparing Costs• What else?

– Interfaces and conversion costs including mapping data fields

– License fees• One-time or annual

– Implementation– Training

• Travel costs– Support and upgrades– Backup: where and when– Other?

• What isn’t included?

• What does pricing include?– Hardware

• Data center only• Peripherals

– Software– Templates– CPT codes– E-prescribing– CCR integration– PHR integration

• What recurring costs?– Software/hardware

maintenance– Upfront or annual

license fees

Comparing Functionalities

Functionalities• Certification?• Continuity of Care Record or Document

(CCR/CCD) capability?• Other criteria…

Functionalities:Information Capture

• What modes of information capture does it offer?– Transcription– Speech recognition: front-end, back-end– Keyboard entry– Digital pen and paper– Handwriting recognition– Point and click– Pull-down menus– Templates, custom or standard– Home monitoring devices– Data entry by patient– Direct from mobile devices (mDevices)– HYBRIDS

Integration Functionalities

• Integration with – Practice management system – ePrescribing – Labs – Payers– Other?

Payer-related Functionalities

• Real-time eligibility determination?– With which payers?

• Real-time charge capture?– With which payers?

Interoperability Functionalities

• Is system interoperable with – Local hospital systems?– Personal health records?– Patient portals?– Patient data entry systems? – Other?

Comparing Usability

Usability• Demonstrations essential

– How does one navigate in the system• Easy• Intuitiveness• Suitable to your preferences/style

– How long does it take to do the same documentation in the EMR vs without the EMR

– How easy is it to query internal data or data from the system or other systems with which it is integrated

• Follow up standard demos with hands-on try-outs

???? to Ask

• Is version demonstrated the one you would be purchasing?

• Downtime?• Interoperability?

– With what and how?

• Interfaces– What data fields are

included?• E-prescribing

– Definition?– Transaction cost?

• Reports– Required?– Custom?

???? to Ask

• Hardware/software needs– ASP?– Hard-wired, wireless,

both?– Devices

• Data submission– What/how, e.g., data to

payers?– Pay for performance

data?

• Scanning– Speed? – Double-sided?– Quality

• Implementation time– Definition? – Does it include

installation, training, loading your data?

– What else?

Contract Considerations

• Exercise due diligence • Consult IT contract attorney• Establish payment milestones

– Do not pay in full upfront

• Address response time– How do they prioritize?

• What about mergers?• Rights to your data

– Escrow clause for source code

Implementation

• Different implementation paths for different practice sizes and specialties

• Realistic timeframes• Staff involvement• Workflow changes• Data conversion: scanning, CCR• Support and maintenance• Backups and recovery

Implementation• Plan and test, plan and test• Policies & procedures

– Privacy, confidentiality, security– Medicolegal requirements– Backups and disaster recovery

• Support and maintenance• Modular or “Big Bang”

– Have flexible timetables

• Appoint a project manager• Assign responsibilities• Modify schedules• Start immediately following training• Implementation never ends

All EMRs Are Not Equal• Price range is enormous

– $1000 to $50,000+/physician

• No best of breed• Features vary • Not easy to change• Not just system but also workflow

makes difference between failure and success

Remember!

• EMRs differ for each application• Different needs, benefits, and

implementation paths for different domains/practices/individuals

• Sharing all information is not the goal• Ask questions! Don’t assume!

Remember!

• Making paper documents electronic does not achieve potential of EMRs

• Not easy• Spend resources to find out• Develop a strategy • Get buy-in• Not just EMRs, also computer-guided,

computer-supported healthcare

ePrescribing Systems

• Standalone ePrescribing or integrated within Ambulatory EMR?

• Both addressed by CCHIT (certification body)

Time Line for Certifying Standalone ePrescribing Systems

• Public comment periods (ended in April)• Publish final 09 Criteria, roadmap, and test

scripts: mid-May • Certification Begins: July 1

Certification: Capabilities for Qualifying ePrescribing Systems

Same for standalone and ambulatory EMRGenerate a medication listSelect medicationsPrint prescriptionsTransmit prescriptions electronicallyConduct safety checks

• Drug information, Inappropriate dose, Inappropriate route. Drug-to-drug interaction, Allergy concerns, Warnings/cautions

Provide information on lower cost alternativesProvide information on formulary or tiered formulary

medications, patient eligibility, and authorization requirements received electronically from patient’s drug plan

Comply with Part D standards for interoperability

2009 Unique Characteristics of Standalone vs Ambulatory EMR

• Focus on core ePrescribing of medications (vs. EHR)

• Problem list management proposed for future years

• Technical criteria geared to align with scope and architecture of ePrescribing standalone solutions

• Criteria included to provide following in an exportable format for migration to other systems– medication list– allergy list– prescription history data

ePrescribing – draft standalone certification criteria

• Identify and maintain a patient record

• Manage patient demographics

• Manage medication list• Manage allergy,

intolerance and adverse reaction list

• Order medications• Eligibility and formulary• Manage medication

orders• Support for drug

interaction and error checking

• Provider demographics• eRx interoperability• Concurrent use• Access control• Audit• Authentication• Data retention,

availability, and destruction

• Technical services• Backup/recovery

Standalone ePrescribing or Integrated within Ambulatory EMR?

• Your choice• Assess what makes sense for your practice• Consider the timeline• Interoperability essential

THANK YOU!

Wishing You a Successful Journey into theNew Era of EMRs, eHealth, ePrescribing

– and beyond

Claudia Tessier LLC617-331-4140

[email protected]

Ethics in EMR

Confidentiality of Electronic Medical Records (EMR) is a Patient’s Right

Christina Williamson, DHA(c),MSN, RN-BC

Veterans Healthcare System of the Ozarks

• Define Preventive Ethics and describe the Preventive Ethics model.

• Identify the key elements of the ISSUES approach to reduce an ethical quality gap.

• Apply the ISSUES approach to an organizational ethical concern.

Learning Objectives

A healthy ethical environment can:◦ improve employee moral◦ enhance productivity◦ improve efficiency

Do the right thing, do it well, and do it for the right reasons.

Ethics Matters

Technical QualityService QualityEthics Quality

Quality in Healthcare

• Decisions and actions• Systems and processes• Environment and culture

Levels of Ethics Quality

Decisions and actions

Systems and processes

Environment and culture

• Shared decision making• Ethical practices in end-of-life care• Privacy and confidentiality• Professionalism• Resource allocation• Business and management• Research• Practices in the workplace

Domains of Ethics in Health Care

• Produce measurable improvements in the organizations ethics practice.

• Quality improvement interventions:– Redesign work processes– Implement checklists, reminders, and decision

support– Develop policies and protocols that promote

ethical practices– Educate patients and staff

Preventive Ethics

• A systematic process for identifying and addressing health care ethics quality gaps on system level ethics issues.

The ISSUES approach

• The process involves six steps: Identify Study Select Undertake Evaluate Sustain

What is the ISSUE?

Be proactive in identifying ethics issues.

Does the issue give rise to an ethical concern or suggest a quality gap?

Specify the improvement goal the team would like to achieve.

IDENTIFY an Issue

The use of electronic medical records and the confidentiality of medical records.

Access to the computerized patient record system.

Patient Concerns

Diagram the process

Gather data about best practices

Gather data current practices

Refine the improvement goal

STUDY the Issue

• Providing the patient with the needed reassurance their information is kept confidential gives them a sense of security, allowing the patient to feel free to make full and frank disclosure of medical or psychosocial history or symptoms.

• Reminding staff of the need to diligently protect patient confidentiality.

The issue selected as a priority by the Preventive Ethics Team

Patient Generated

AddressPhone numberNext of kinDate of birthMarital statusGenderReligionEligibilityMilitary serviceService connectionMedical historySensitive record

Healthcare Team Generated

AppointmentsAllergiesVitalsMedicationsAppointmentConsultsInpatient staysLabMental Health visitsOncology reportsPathology reportsOutpatient visits

Diagram the process behind the relevant practice

Electronic data sharing allows the consumer full control of the health information.

Patient Safety Institute promotes a common record controlled by the patient and the provider.

Geisinger Health System created a fully integrated medical record with electronic communication between the physicians and accessible to the patient and the caregiver.

Best Practices

A Computerized Patient Record System integrates various clinical packages including: ◦ Order Entry◦ Progress Notes ◦ Discharge Summaries◦ Consult Results ◦ Vital Signs ◦ Problem List◦ Progress Notes◦ Discharge Summaries ◦ Consult Results ◦ Lab Results◦ Imaging Reports and ◦ Medication Profiles

Current Practices

Identify the major causes of the ethics gap.◦ Root Cause Analysis◦ Fishbone or Cause-and effect diagram

Brainstorm strategies to narrow the gap.

Choose one or more strategy.

SELECT a Strategy

Major Cause(s) of the Ethics Quality Gap

Identify personnel limits on access and disclosure.

Identify processes in place that state information can not be disclosed without consent.

Security measures to protect personal information.

Information shared outside of CPRS is encrypted or sent within a secure site.

Inform patients of limits of confidentiality protection.

Strategies to Narrow the Gap

Identify the steps needed to carry out the strategy.

Develop measures to assess and evaluate.

Execute the plan, make corrections based on what works and what doesn’t.

UNDERTAKE a Plan

• Information will be shared verbally and in writing.

• Patients will better understand the reason why.

• Information shared will include:– the importance of a common health record– the VHA supports the exchange of clinical data as

an effective method to improve the veteran’s health.

Our Plan

Check the results

Adjust as necessary

Evaluate the ISSUES process

EVALUATE and Adjust

Clinic providers felt they do not have time to go into detail as it relates to the use of an electronic medical record.

Written information or patient care material addressing this issue is not readily available.

Patients’ expressed unwillingness to have their clinical data shared.

Identified Barriers

The development of a script that summarizes why and the importance of sharing healthcare information.

Information to the inpatient handbook reads, ‘Information disclosure and confidentiality’: Your medical record will be kept confidential. Access to your electronic medical record, within the VA system, may be viewed by authorized VA personnel only.

MyHealthy Vet program.

Solutions

Integrate the change into standard operating procedures.

Disseminate the improvement.

Continue monitoring.

SUSTAIN and Spread

Customer service surveys

Annual SHEP (inpatient and outpatient) report

Self reported patient complaints

Patient advocate feedback

Monitoring tools

• MRSA testing post mortem.

• Conflicting patient and provider expectations.

• Assessing decision making capacity.

• Do all patient with dementia lack decision making capacity?

Other ISSUES approaches

• From ……– Reactive– Case based– Narrow– Silos– Punishment– Rules

• To ……– Proactive– Systems oriented– Comprehensive– Collaboration– Motivation– Rules & Values

Conclusion

Activity

• Discuss the importance of Medical records and describe how could EMR support convenience and safety to hospital staff and the patient.

• Describe the measures you adopt to in adherence of EMR system to ethics and patient rights ?

THANK YOU

Documents

MEDICAL RECORDS Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical Administration ) 1.Medical Records Department 2.Electronic medical records (EMR) 3.Ethics