Module 11 1.Introduction to HIS 2.Medical records department 3. Electronic Medical records 4.Patient rights in e health 5.Telemedicine 6. Soft wear & Medical

Module 11 1. Introduction to HIS2. Medical records department 3. Electronic Medical records 4. Patient rights in e health 5. Telemedicine 6. Soft wear & Medical equipments7. Health Information System /

Public health information system

Evaluation methodology

• Course work and activities – 20%• Assignment – 40%• Final paper – 5 essay questions and 40 MCQs

– 40%

Hospital Information System ( HIS)

Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical

Administration)

1. Introduction

• Hospital consists of multiple variety of function performed by different categories of people

• With limited resources these personnel are expected to produce an output with an acceptable quality.

• Strict regulatory process and more documentation in the hospital process have hampered these personnel performing assigned actual technical work, resulting unproductive low quality service outputs. EX. Nursing care

Justification

• Due to Scarce Human Resources, existing Human resource should utilize in a most productive and cost effective manner

• Hospital Information system will make people more efficient by collecting & distributing information faster, making use of the same human resource.

• Efficient MIS essential for the hospitals in today’s context.

Primary objectives of HIS

1. To make a cost effective hospital2. To provide quality services to their patients3. To enhance the decision making process4. To support user confidence 5. To boost hospital professionals commitment

Requirement of a HIS in a hospital

• Daily management of operations• Competitive planning strategy• Controlling dissemination of information• Processing volumes of data• Providing information for medical & financial auditing• Inventory management• Interaction between department heads for planning,

coordination, & control activates.• Provision of information for national level policy,

decision making.

2. Benefits of HIS• Health administration: Per patient information administrative work

and making him more competitive in his work, prepared for auditing & legal demands.

• Medical research & development for response & preparedness.• Improvement in Quality & efficiency in patient management:

Pictorial & image data presentation increases for medical imaging services

• Process coordination & improvement: Networking of units• Increase efficiency of HR: It is estimated 40% of HR time is spent on

in formation gathering, processing & disseminating work.• To identify & improve areas of inefficient areas in terms of service

delivery & cost.

3. Current Gaps in HIS in hospitals

• Management & medical systems: Underutilization of available data in day-to-day management, unavailability of soft ware & hard ware.

• Hospital & clinical systems: Incomplete data sheets, Lower man power

• Hospital staff & data base developers: little or no knowledge in respective personnel regarding IT & hospital activities. Poor communication & lack of interest of the mentioned categories

4. Methodology

• There are several approaches to constructing HIS.• Supporting activities of functions

– CEOs information system• Point of scale method (POS)

– Build around the Patient• Top down method

– Build around Cooperate plan, targets, to functional goals

• Local Area Net work method (LAN)• Analogous system

5. Functional modules in a HIS

• There are two major categories in HIS1. Clinical 2. Administrative.

A. Clinical • Ward management• OPD management• Operation Theater• CSSD• Transfusion services• Ambulance services• Medical records• Special unit management: ICU, ETU,• Labor room and PBU• Diagnostic services: • Laboratory, Radiology, ECG, & EEG

B. Administration

• Front office• Registration• Appointments• OPD Administration• OPD billing & IPD billing• Stores• Pharmacy• Marketing• Financial accounting

7. Implementation strategy of HIS

• Development of long-term plan for five-year period with short tem, annual plans.

• Identification of current operational problems & need for soft ware solutions, making phase wise deployment of those solutions.

• Site visit & determining estimating how the soft & hard wear enhance work process.

• Cost effective Method of the development of the soft ware; Purchase, in-house development or customization of developed soft ware.

• Placement of computers, printers in points of revenue generation & service centers and the cost.

• Determine the net work configuration: local & other connections• Develop & plan for a training programme • Introduce audit & review systems, operation delivery systems • Development of implementation strategy

8. Key activities of HIS implementation

• Determination of priorities• Defining architecture• Outsourcing needed activities• Evaluate & select solution • Evaluate criterion of applications• Customize & implement applications• Building computer premises• Acquire the resources• Install the equipment • Establish task force• Site visit• Empower uses

9. Future Technologies

• Telemedicine • Medical records• Smart Card• Digital library• Multimedia

10. Resources for installing HIS

• Operating system• Data Base management• Antivirus soft ware• Server• Data base backup drive• Ups• Terminals• Hub• Manpower• EDP room• Cables ,Panels & outlets

Thank You!

MEDICAL RECORDSdepartment

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.

THANK YOU

DATA EXTRACTION FOR CLINICAL CODING

• Objective

• To build on the participant’s experience in extraction of data from medical records, focussing on identifying data items of particular importance for morbidity & mortality coding, and coding quality

Lesson Plan• 1. Sources of data for coding• 2. Responsibilities• 3. Data abstraction• 4. Main diagnosis • 5. Accurate coding• 6. Quality assurance in morbidity data collections

– Coding quality– Source documentation quality

• 7. Auditing of source documents

Introduction

• For clinical coding to be as valuable as possible it is critical the coder has:

• access to a comprehensive and accurate medical record,

• the skills to extract all pertinent data for coding,• access to clinicians to ask questions and seek

clarification

Sources of clinical data for coding

• Morbidity coding is usually performed after the patient has left the hospital

• Information to be coded is abstracted from the whole medical record

• The coding process has two parts:– analysis of the medical record– allocation of correct codes

Responsibilities• Coders

– reviewing the entire record – verifying the record contains appropriate documentation– coding specifically and accurately the conditions or diagnoses

treated or affecting a patient’s care– referring the record to clinicians for clarification

• Clinicians– recording accurate and complete clinical documentation in the

medical record– recording all diagnoses on the front summary sheet– identifying the main condition

7 Steps for Abstraction of Relevant Data from the Medical Record

1. Read the front sheet of the relevant admission2. Read the discharge summary or other correspondence3. Compare any diagnosis in the discharge summary/letter

with that recorded as admission or provisional diagnosis and with that recorded on the front sheet

4. Read the history and physical examination5. Identify relevant procedures6. Review the entire record7. Clarify information with the clinician if necessary

When to consult with the Medical Officer

• If conflicting, incomplete or ambiguous information is found or if documentation is unclear

• Check with the attending medical officer, the medical officer who filled in the front sheet

or the radiologist or pathologist

• Coding should be a cooperative and collaborative effort between the clinician and the coder

What to code?

• Main condition or principal diagnosis

• +/- other or secondary conditions

• +/- procedures, operations and interventions

Selecting the Main Condition or Main Diagnosis

• Consider those conditions which:– caused the patient to be admitted– were treated and/or investigated during the acute

admission– affected the treatment given and/or the length of

stay– developed during the admission

• The main diagnosis can then be selected from these conditions

WHO definition of main diagnosis or main condition

• …the diagnosis established at the end of the episode of care to be the condition primarily responsible for the patient receiving treatment or being investigated…that condition that is determined to have been mainly responsible for the episode of health care...

• (ICD-10, volume 2, 4.4)

Secondary diagnosis / Other condition

a diagnosis that either co-exists with the main diagnosis at the time of admission, or which appears during the episode of care

complications and comorbidities

What is a comorbidity?

• A disease that accompanies the main diagnosis and requires treatment and additional care, in addition to the treatment provided for the condition for which the patient was admitted

What is a complication?

• A disease that appears during the episode of care, due to a pre-existing condition or arising as a result of the care received by the patient

Problems with determining the main diagnosis

• absence of a clear-cut main diagnosis• minor condition recorded as main diagnosis• diagnosis recorded in general or ill-defined terms• uncertainty of diagnosis• symptoms or signs listed as the main diagnosis• no diagnosis recorded

What is accurate coding?• each diagnosis must be assigned its correct code

(or codes)• Codes should be as complete as possible• all diagnoses affecting the care of the patient

and procedures performed during the episode of care should be assigned codes

• codes must be sequenced correctly with the main diagnosis listed first

• morbidity coding rules in volume 2 of ICD-10 should be followed

To ensure accurate coding:

• Coders should be familiar:– with anatomy and physiology of the human

body– with medical terminology so that disease

descriptions can be interpreted into ICD language

– with disease processes and medical practice to be able to understand etiology, pathology, symptoms, signs, diagnostic procedures, etc.

To ensure accurate coding:

• Coders should also have:

– an understanding of the content of the medical record

– experience with the actual medical records so specific details can be located

– detailed knowledge of the coding system being used

– an understanding of data reporting requirements

Quality Assurance in Morbidity Data Collection

• Increasing use of morbidity data leads to an increasing concern for the reliability of data

• Sources of error in MR information systems:– documentation of the patient’s care and

condition during the episode in hospital– coding the information in the medical record– processing the coded information

Coding accuracy

• Three dimensions of coding accuracy:

– accuracy and completeness of individual codes– accuracy of the totality of codes to ensure they

reflect all diagnoses treated; and – accuracy in the sequence in which the codes are

recorded, particularly in selection of the main condition

Common sources of coding errors:• Clerical

– careless mistakes, transposing numbers• Judgmental

– wrong subjective decisions taken• Knowledge

– mistakes due to lack of coder knowledge• Systematic

– errors in the process of coding or problems with the environment in which coders work

• Documentation– incomplete, inaccurate, ambiguous, conflicting– illegible

•

•

What affects coding quality?– Errors in the choice of code– Lack of feedback– Casemix – number and type of cases to be

coded– Use of coding conventions and coding rules– Lack of clarity in coding books– Changes in coding practice

What affects coding quality?– Documentation – Incomplete medical records– Availability of records– Coder/clinician communication– Data entry– System edits– Forms design

What affects coding quality?

– Workload– Education– Human resources– Environment– The individual– Reference material

Coder/Clinician Communication is important for:

• Team approach to achieve complete and accurate documentation

• Clinician’s responsibility to record accurate diagnoses and procedures and document fully the episode of care

• Coder’s responsibility to review and use documentation; use standard definitions, use their skill and knowledge of the current coding system

Why has communication traditionally been lacking?

• lack of understanding of coding as a process and of the importance of coded data

• clinicians do not feel a sense of ownership of the classification system or the fact that the coded data reflect their work

• coders feel intimidated about asking questions, seeking advice or asking about clinical issues

Ways of improving communication• encourage clinicians to attend coding meetings in

the clinical coding/medical record department• request coders attend clinician meetings

conducted by each clinical specialty• organise coding service to allow coders to

specialise• clinician involvement in the development of

coding guidelines• education for clinicians and coders

Five steps for quality control of coding:

• establishment of objective criteria for coding quality

• measurement of performance• analysis of problems identified• action taken to correct identified problems• review of performance after corrective

action

Auditing

• To inspect and verify

• To determine the degree of accuracy in ICD coding based on coding rules and coding conventions

Audit principles

• Coder A (original coder)

• Coder B (auditor)

• Coder C (independent adjudicator)

Sample selection

• Period of audit

• Audit sample – Random sample – Target sample

Sample selection

• Random– representative of morbidity database– suitable for benchmarking– only some records will have errors– 5% sample size recommended– random number generator or table

Sample selection

• Target– defined by coder-in-charge or auditor– cases selected because of known or suspected

errors or difficult cases or because a new coder has started work

– only some records will have errors

Retrieving and preparing clinical records

• Retrieve original record

• Temporarily remove or obscure coded data

Recoding process

• Coder B– Recodes each record– Assigns error categories if errors found – tries

to determine what has caused the error

• If there is a dispute, Coder C– Recodes each record– Assigns error categories

Coder C recoding

• Recodes record ‘blind’

• Discusses code differences with Coder A and Coder B

• Make final decision about correct codes

• Assign errors to error categories

Examine and analyse results

• Need to develop a form for reporting of results– Scoring Tool form– Summary Data form

• The summary data forms the basis for a report about coding quality and can be used to compare data at different time periods.

Questions to ask when reviewing coding:

• Is the main diagnosis correctly identified?• Are all secondary diagnoses coded?• Are all diagnoses coded?• Are all diagnoses and procedures coded

correctly?• Have the codes been transcribed or data

entered correctly?

Coder competency is influenced by:

– Knowledge– Skill– Attitude– Behaviour– Experience

Ways of improving coder competency:

– Training (initial education and training)– Continuing education (ongoing education)– Reference materials– Coder peer support– Recognition of competence

Documentation

• Key elements - accurate, complete, timely, legible

• Source document - quality of the clinical record

• Documentation errors - Main condition, other diagnoses, operations

Documentation requirements – what clinical staff should write:

• Do write:• Date and time of entries• Purpose of entry eg. admission note, planned review,

asked to see patient, end of shift report• History and examination findings – be succinct!• Assessment of current situation• Plan for what needs to happen now and later• Print name and sign, include position, contact details for

every entry• Use only approved abbreviations• Complete discharge summary and front sheet

Documentation requirements – what clinical staff should not write:

• Don’t write:• A repeat of clinical details previously written –

this wastes your’s and other’s time and wastes paper

• Anything unpleasant, rude, or critical of either relatives, patients or staff

• Anything that is not true or does not reflect reality

• Backdated entries or changes to existing entries

Documentation policy• Need to ensure there is a documentation policy in place so

clinical staff know the requirements for documentation and can be assessed against those requirements

• See sample Guidelines for Medical Record and Clinical documentation

• What are the requirements for clinical documentation in your country? Are these written in a policy? Do clinical staff know what they should be documenting?

Ways of improving documentation• 1. record design - well structured, standard order,

complete, cover the scope of the care

• 2. forms design - elicit information needed for patient care and coding, easy to use, legible, designed in conjunction with health professionals who will use them

• 3. education– clinicians - documentation is as much part of

clinical care as direct patient contact– management - channel resources and

enthusiasm into this area

Assessment of documentation quality

• Conduct a regular audit of documentation quality

• Use standard data collection form – can compare results over time to determine improvements

• Consider the data items that must be presented in a documentation quality report and the format in which they should be recorded

• See example of documentation audit sheet

Process for a documentation audit• Complete at least 1 audit per year

• Select a random sample of 5% of discharges in a given month, or at least 10 records (whichever is the higher number) should be audited

• Select records from a printout of the Medical Record or Bedhead Ticket numbers of all discharges in a month ordered by discharge date. Select every 20th medical record number on list for audit. If record selected is not available, the next record on the list should be selected

• The audit relates to documentation within the selected admission only

Medical Record documentation Assessment

• In country groups, using the sample medical records brought with you, complete a documentation audit for each record.

• What are the major problems you have found?

• What are some way that these might be addressed?

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]

Developing a hospital information system in a hospital

The project

• Planning • Implementation • Monitoring • Evaluation and feed back

The project plan

• Identification of the “needs gap”• Plan a system as per the requirement to

improve the quality , reduce cost and other resource constrains

Identification of the needs gap

• Study the process flow • Identify the bottle necks and red tapes and

time , money and resource wasting area . Also the high risk areas needs quality improvement

Process flow

• Service industry • Services process • Core process – Direct Patient care services • Support process – Administrative /support

services• Consider core service initially and then move

on to support process ( depending on the cost , time , quality and other resource importance

Patient care process

• Identify services units – OPD, IPD, CCU, ETU etc.

• Select Key result areas – functions • Functions – sub unit level

– OPD -reception Registration , Payment

• Activities • Tasks

OPD

• Reception • Registration • Payments • Consultation • Investigation • Treatment • Dispensing

The process

• Study the process as per the core patient care services

• Identify the Key result areas• Identify the functions • Study the information flow • Validate the current methods• Identify gaps • Propose the system support • Also look at integration of each units

Activity 01

• Develop a process and the information need for a IPD services

Selection of a system

• Select / modify or develop system as per the need

• Step by step implementation - modular fashion • Unit by unit as per the process flow – OPD to IPD

and then to CCU• Closely follow the “ Human Response”• Monitoring and feed back essential • Clinical and administrative modules

Clinical modules • Ward management• OPD management• Operation Theater• Ambulance services• Medical records• Special unit management: ICU, ETU, Labor room and

PBU• Transfusion services, Ambulance services• Diagnostic services: Laboratory, Radiology, ECG, & EEG

Administration modules

• Front office• Registration• Appointments• OPD Administration• OPD billing & IPD billing• Stores• Pharmacy• Marketing• Financial accounting• Human resources

• Catering• House keeping• Purchasing• Customer care• Security

HIS modules

Advanced-Clinical-Workflow.ppt

Activity 02

• Develop a HIS for a 30 bed hospital • Each Main units – IPD , OPD, Investigations ,

CCU • Consider Data storage as well • Use of E services

Tele Medicine

• Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in critical care and emergency situations.

• Diagnosis , treatment and monitoring and rehabilatation

http://en.wikipedia.org/wiki/Telecommunication

http://en.wikipedia.org/wiki/Information_technology

http://en.wikipedia.org/wiki/Health_care

http://en.wikipedia.org/wiki/Trauma_(medicine)

http://en.wikipedia.org/wiki/Emergency_medicine

Health Information system

• Public health system• Description • Modules

Activity 03

• Discuss the evaluation of Tele Medicine and its impact to future hospital services.

Thank you !

Documents

Module 11 1.Introduction to HIS 2.Medical records department 3. Electronic Medical records 4.Patient rights in e health 5.Telemedicine 6. Soft wear & Medical