1 / 32

The Electronic Record: Planning is Crucial!

The Electronic Record: Planning is Crucial!. Lynn Edwards. MBA, RHIT, CHSP. Vision Statement. To assist you with the planning & organization of your electronic health record by utilizing available resources to benefit patient care. Goal and Objective.

brac
Download Presentation

The Electronic Record: Planning is Crucial!

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Electronic Record: Planning is Crucial! Lynn Edwards. MBA, RHIT, CHSP CSRHA 2009 L. Edwards

  2. Vision Statement • To assist you with the planning & organization of your electronic health record by utilizing available resources to benefit patient care. CSRHA 2009 L. Edwards

  3. Goal and Objective • Better understanding of what it takes to plan and implement an electronic medical record in an acute and clinic setting • Envision what is best for your facility - Electronic vs hybrid CSRHA 2009 L. Edwards

  4. Basic Functions of EMR Systems • Order entry/management • Health information and data • Ancillary results management • Decision support • Electronic communications & connectivity • Patient support • Administrative processes – chart audit • Reporting & population health management CSRHA 2009 L. Edwards

  5. Provide Organization Education/Awareness • Develop proposal • Select timing • Affected areas • Impact • Opportunities • How to initiate planning • Education • Meetings • Webinars CSRHA 2009 L. Edwards

  6. Organizing • Committee • Surveys • What are your needs, expectations • Who to include • When • How and How much • Management of users • Number & structure of document titles • Indexing CSRHA 2009 L. Edwards

  7. Committee Considerations • What departments and personnel to include in planning from the ground up • Software and hardware selection process; determining need and bottom line – • Include demos from several companies • Program compatibility issues • Back-file scanning…making it work for you CSRHA 2009 L. Edwards

  8. Committee Considerations continued • Policy and procedure changes • Legal health record • Late effects on release of information, workflow, access, retention and destruction • FTE savings…fact or fiction CSRHA 2009 L. Edwards

  9. Who to include? • Representatives from: • Support services • Physicians • Nurses • Managers • Board • Administration • IT CSRHA 2009 L. Edwards

  10. Buy-in • Education & Training – “convincing” and Communication • Paperless • No storage • Less Employees • Ease of use • State the vision and long term direction • Buy-in CSRHA 2009 L. Edwards

  11. Software and Hardware • After you determine what is needed • Choosing a program • Compatibility issues – bridges & cost • EHR, hybrid, paper – archival scanning • Technical support- hardware, cost • Scheduling, on-call assistance • Scanners • Forms, Labels CSRHA 2009 L. Edwards

  12. Scanning • When to scan – complete, signed, versions? Separation at scanning • Concurrent or retro or both • Indexing and labeling • How far back • Outside scanning – have it done on premises = control CSRHA 2009 L. Edwards

  13. Scanning continued • Any problem can impede progress • Tracking completed record • How will you handle photos, etc. • Consents • Color • Clarity • Destruction – fact or fiction? CSRHA 2009 L. Edwards

  14. Policies & Procedures • What is your legal health record? • HIPAA security • Access • Retention • Destruction • What labeling is required • How will you index documents CSRHA 2009 L. Edwards

  15. HIM Issues • Maintaining workflow • Maintaining quality • Storage issues • Increased quality review • P&Ps • Disclosure Log CSRHA 2009 L. Edwards

  16. HIM Issues continued • Downtime • Indexing – by diagnosis & not patient complaint • Scary issues • Guarantor • Phantom findings • Patient record found in another patients record – • Admission errors CSRHA 2009 L. Edwards

  17. Late Effects • Release of Information • Use of outside vendors, access, training • Workflow • Late receipt of records • Rescanning • Access • Non-users – physician, administration • Vendors • Delivery systems – satellite delay CSRHA 2009 L. Edwards

  18. Late Effects continued • Retention • Destruction CSRHA 2009 L. Edwards

  19. FTE Savings – Fact or Fiction • Brilliant idea • Lost ½ FTE • And, the ability to backscan • No real savings –24/7 • Quality • Time to check & index • Paper, storage CSRHA 2009 L. Edwards

  20. Our System • Host System • Digital-One & Sphere • Decentralized then centralized • All areas exclude clinic • Physician buy-in CSRHA 2009 L. Edwards

  21. DigitalOne – Patient Chart CSRHA 2009 L. Edwards

  22. DigitalOne – Audit Trail CSRHA 2009 L. Edwards

  23. DigitalOne – Print/Fax/Email CSRHA 2009 L. Edwards

  24. Typical Workflow • Document • Prep • Scan • Machine maintenance • Document feed • Shingled documents • Jam problems • Index • Proper labeling • Buy-in CSRHA 2009 L. Edwards

  25. Typical Workflow continued • Quality Check & Release • Early – check every step & watch for training needs • Monitor and give feedback • Initiate counseling and discipline • Initiate quality check & accountability • 1 clerk initiates • 2 clerks check • 1 HIM clerk reviews • Feedback to Admissions CSRHA 2009 L. Edwards

  26. How to respond to go-live problems • Lengthened timeline • One-on-one training and support ($) • Improved physician review, oversight, testing • Intensive cooperation effort with vendor to address functionality concerns • 24/7 support – technical, documents, etc CSRHA 2009 L. Edwards

  27. Additions/Modifications • HIPAA statement on access to system • What to do with “celebrities” • Limitations to users according to “need to know” • Removal of access • Indexing modification • Chart order • Add Disclosure Log CSRHA 2009 L. Edwards

  28. Today’s Situation • Intensive quality control • Same # of employees – expand to 7 days • Same storage issues • Ease to provide records- also problematic • Paper chart reviews CSRHA 2009 L. Edwards

  29. Today’s Situation • Lack of use by providers • Still poor legibility – coders, billing • Need to auto-feed lab, x-ray, transcription • Look at available options to your system • Tablets • Cost • Physician office involvement/RHIO • Advantages/Disadvantages CSRHA 2009 L. Edwards

  30. Benefits • Ease of access • Release of Information • Patient care • Billing • Coding • Physicians • QA studies • Reviewing agency access - RAC CSRHA 2009 L. Edwards

  31. Summary • Success based on usability, ease of access, buy-in, change of habits • Quality control • Close involvement of organizational medical record committees. • Universal vision • Administrative support • Persistence!!! EMR often painful, especially early. Wounds heal slowly. • Communication! Commitment! CSRHA 2009 L. Edwards

  32. Contact • Lynn Edwards (909) 878-8217 • lynn.edwards@bvchd.com CSRHA 2009 L. Edwards

More Related