Direct Data Entry e-Forms: the bridge between scanned records and the paperless hospital

1. Direct Data Entry e-Forms: the bridge between scanned records and the paperless hospital Tung Nguyen BHIM/BHS (LaTrobe) BOSSnet Victorian Account Manager

3. Agenda • Introduction • The current situation: Paper based forms in a scanned record • The solution: Electronic Forms • Why use e-Forms? • - Issues • - Aspirations & reality • - Costs & Benefits • Key messages • Transcription requirements (simple versus complex) • Key messages • General discussion and questions

4. Introduction – who am I? • Health Information Manager. • Worked across four tertiary health services that have implemented a scanned medical record solution. • Currently managing a Digital Medical Record.

5. Used to record diary-like statements of work and treatment outcomes for clinicians. • Recognisedissues with timely access (scanning backlogs), storage and retrieval. • Need to document the same data in multiple times on multiple forms. • Limited ability to collect and share data in a standardised format. • Readability issues of handwritten forms. The current situation: Paper forms in a scanned record

6. The solution: Electronic Forms • Data collection tools. • Input can be simple (e.g. free text and drop down boxes) or complex (e.g. abstracted from other clinical tools and systems). • Have the ability to output the data in various ways to assist clinical care (e.g. graph points on a growth charts). • Enable point in time data collection.

7. Issues & Considerations • Change management • - attitudes & behaviours • - Planning • Identify workflows that do not currently exist. • Start with small steps (e.g. simple transcription e-Forms in a targeted department). • Consider adopting shared terminologies and concepts (e.g. ICD-10-AM). • Work towards reducing and eliminating the issues caused with written forms.

8. Costs • A clinical system needs to be in place to support e-Forms. • Sufficient availability of clinical access devices. • - Clinical drive for mobile devices due to advancements in technology (e.g. smart phones and iPads). • Clinical buy-in from stakeholders. • Operational and ongoing support.

9. Benefits • Improve data readability (for accurate diagnoses, referrals, assessments, care plans etc). • Collect standarised data to improve service quality through research, billing and State/Federal minimum data sets. • Instant storage and access to patient data in real time (no delays in scanning). • Linkage to clinical systems, protocols for decision support. • Enables data to be manipulated and displayed in different formats. • You are in control of the data.

10. The reality of using e-Forms • Changes to attitudes and workflows take time, however there is a great push from clinical teams to implement direct data entry e-Forms . • Health services must ensure the demand for e-Forms is met with the supply of sufficient clinical access devices. • Requires buy in from all stakeholders. • Requires process/work flow redesign.

11. Simple e-Forms • Examples include: • - Admission forms • - Coding sheet • - Questionaires • Used to tidy up existing paper forms. • Allow clinicians to ease into the change from hand writing to direct data entry. • Immediate benefits seen.

14. Complex e-Forms • Examples include: • - Discharge Summaries • - Progress Notes • - Growth Charts • Should integrate with other tools to provide a complete picture of episode of care. • - Medication Management (allergies and contraindications) • - Results (Pathology & Radiology) • - Pharmacy (inventories) • Provide clinical decision support.

22. Summary • The ultimate goal for a clinical environment should be paperless. • Change requires time and planning. • Consider the use of standardisedterminologies and concepts. • E-Forms should be able to share data with other clinical systems and tools.

23. Tung Nguyen BHIM/BHS (LaTrobe) BOSSnet Victorian Account Manager Email: tung.nguyen@coremedicalsolutions.com Phone: 0403 616 948 Website: www.coremedicalsolutions.com