Electronic Health Record What you should know

What is hCare? HCA’s Electronic Health Record – hCare: Ties together a patient’s health information from multiple systems to provide one complete view Whether the information comes from a hospital, doctor’s office, clinic, or lab, it will be presented in a structured, standardized format One of the core components of hCare includes the hCare Clinician Portal Speaker Notes: CSG hCare is the name of HCA's electronic health record. It's more than the portal, it's the combination of all components that create an electronic health record. These components will roll out over time. The initial components lay the foundation for our comprehensive electronic health record.

What is the Clinician Portal? Physician electronic access point for clinical information Integrated systems Simplified sign-on—one username, one password Simplified Remote Access – no more tokens User-friendly, intuitive interface Access to complete patient list Resources section Clinical references Training modules Facility-specific information Accessible from hospital, home, office, or while traveling Speaker Notes: CSG The portal is a viewer that pulls together clinical information for patients. It provides a user-friendly, intuitive interface for physicians, making clinical data accessible from within the hospital or remotely via simplified remote access.

Access – the first step to providing a single point of entry to integrated, clinical patient data Intuitive, user-friendly interface One sign-on for all integrated systems (e.g., MEDITECH, PACs, MUSE, CVIS) e-Signature capability via HPF tab in portal for completing unsigned orders and charts Accessible from any internet-capable computer, if proper system requirements are met Organized and standardized to reduce medical error Provides inpatient management system

The portal integrates facility-based clinical systems, providing physicians with one-stop shopping for clinical data. Dictated reports, vitals, labs, test results EKGs Fetal monitoring strips Cardiology images (PACS) and reports Labs Radiology images (PACS) and reports 5

Enhancements to the clinician portal 4/2 - North Sub & Spalding 4/16 - Skyridge 4/30 - Swedish 5/14 - PSL 6/4 - Rose 6/18 - Aurora Coming Soon! Enhancements to the clinician portal

Electronic signature and record completion Clinician Portal-Enhancements Electronic signature and record completion Post-discharge records available electronically These new features are available via Horizon Patient Folder (HPF)—a new enabling technology supported by the Health Information Management Shared Services Initiative—and will be available from within the clinician portal. Speaker Notes: CSG The clinician portal will also provide reference resources for physicians – including training modules for using the portal and facility and division-specific information And because it's web-based, physicians will be able to access the portal via simplified remote access.

Physician Access to Medical Records Current Future Post Discharge Chart Completion & Signatures Paper patient medical record and a variety of paper forms In the HIM Department 100% online via the hCare Clinician Portal Accessible by most PCs using an internet connection Review Patient Medical Records Process Paper medical record and a variety of systems such as MEDITECH, MUSE, OB Link, hCare Clinician Portal, and Mobility Prior to Discharge: Patient medical records exist in paper form prior to discharge Post discharge: (after scanning at HSC) Complete medical record will be accessible only online Access and review discharged patient medical records using the hCare Clinician Portal Speaker Notes: The slide compares today’s world of Post Discharge record access to the future state after the implementation of the hCare Clinician Portal with HPF. Medical records today are accessed via the HIM department for record completion/deficiency management. The paper medical record is limited to one physician at a time. In the future state medical records are accessible using most PCs using an internet connection and multiple physicians can access the same medical record at the same time for improved deficiency management. Reviewing the paper medical record. The working chart will continue to be a paper document. However, electronic feeds of some data will enable physicians to view data on line and in the working chart. The paper post discharge medical record is sent to the HSC where paper only items are scanned and joined with the items/forms sent electronically during the patient visit. Once the record is scanned, etc it is available for view/review for all historical visits on line via the clinician portal.

Screenshot: Managing incompletes Speaker Notes: This screen shot displays how incompletes are presented. Below is some detailed information about the data elements found on this screen. Details surrounding the management of incompletes/deficiencies is included as part of the education and training process for physicians. Detailed information about this screen. Once a physician selects the Incompletes tab from the top of the page. The list of incomplete records displays. *Please note this example displays a “Deficiencies” tab. The production system tab states “Incompletes”. The number to the right of the tab label identifies the number of deficiencies for this physician. Deficiencies are displayed in reverse date order and are color coded by status. Deficiency types are displayed at the top left and include the number associated with the type of deficiency. The number of days deficient are located to the right of the status. Black identifies the privileges are suspended. Red identifies that privileges are pending suspension. To begin processing deficiencies the physician will select “process all” to process all deficiencies.

Screenshot: PIN entry for e-Signature Speaker Notes: This screen displays the PIN or e-Signature function. Detailed information about this function is below and a fully explanation provided as part of the training and education process. Detailed information: Once a physician selects process all. The PIN screen appears. *PIN entry is required only once per session. Upon clicking the “Ok” button the deficiency viewer opens where the physician will begin working their deficiencies.