Medical Records Department Electronic medical records (EMR)

MEDICAL RECORDS Dr Kithsiri Edirisinghe MBBS , MSc, MD ( Medical Administration )
Medical Records Department Electronic medical records (EMR) 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

Description 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.

DEFINITION OF 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.

Benefits of the MRD Patients Doctors Hospital Teachers Students
For research work National & International agencies

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
OPD and Clinic registration department Wards Central Admission Office Medical Record Department Afetr completion of Reccords Assembling ADMN. & Discharge analysis Hospital statistics prepared Monthly/Yearly Medical Record is filled for perusal of Patients/claims/research purposes. Storage Area

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. Dealing with Medico Legal records and attending the courts on summary. Arrangement & Supervision of enquiry and admission office. Arrangement & Supervision of OPD registration Management of disability boards. Management of Medical Examination Management of Mortality Review Committee Meetings (Twice month) 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. National list for Tabulation of Morbidity and Mortality (IMMR) Monthly Health Bulletin Monthly report of Polio Cases Monthly report of GWEP Report of cataract operations Report on the notifiable disease Monthly report of communicable diseases Monthly report of MNT (Paed & Gynae)

10. Monthly report of AIDS cases
11. Monthly report of Anti Rabic cases 12. Monthly report of STD 13. 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 Deliveries 17. Monthly report of Family Planning 18. Monthly report of Medicine, DRT, Polio, TT 19. Monthly report of Leprosy cases 20. Weekly report of Polio 21. 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 cases 24. Weekly report of Pyogenic Meningitis 25. Weekly report of Gastro-enteritis, Cholera 26. Daily report of Noticeable Disease under surveillance.

Electronic Medical Records V 05
3. EMR Electronic Medical Records V 05

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

EMR Hospital Consumer 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 healthcare 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?

What Outcomes Are You Seeking?
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 care Improved 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 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?
Obsolescence Ease of integration Concerns about ROI Solutions not right for you Lack of demonstration site Data/chart conversion Increase documentation Other? Expense Selection difficulties Staff resistance Time & effort required Incompatibility of hardware/software Ease of use Security Lack of technical expertise

What Do You Want to Achieve?
More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care When you are ready to look at systems What do you want to achieve?

What Do You Want To Achieve?
Savings from Transcription Better Coding (not guaranteed) Patient Information Capture Speech Recognition System Efficiency Back-end Speech Recognition Front-end Speech Recognition More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care Automated coding Higher revenues from ‘lost’ charges and better coding Success varies

Connectivity with Medical Community
What Do You Want To Achieve? Connectivity with Medical Community Patient satisfaction Referrals Reports Labs Hospital Communication CCR Communication by Refills Trust Efficiency/convenience Less waiting time Technology attraction Computer-generated patient education Guidance to websites Web portals More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care

Remote Computing and Remote Documentation
What Do You Want To Achieve? Remote Computing and Remote Documentation Working at home or anywhere Arranging your time accordingly More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care Better Quality of Life

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 More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care

Computer and Internet Support for Decision Making
What Do You Want To Achieve? Computer and Internet Support for Decision Making Formularies Diagnostic information Information about medications Other decision support info More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care

Reports More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care Query system by condition or medication Follow-up and reminders Standard reports Ad hoc and other reports

Patient Information More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care Receive patient information electronically Integrate and create CCR All insurance information Health status from other providers

Improved Quality of Care
What Do You Want To Achieve? Improved Quality of Care More money/savings/ROI Better competitiveness Remote working Workflow benefits Better decision support Easier reporting Better information about patients Improved quality of care Health maintenance Disease monitoring Practice guidelines Patient education Lab tables/interfaces Data!!!

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 does pricing include? What else?
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 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?

Comparing 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?

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 Data submission Scanning
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 No best of breed
$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 EMR Generate a medication list Select medications Print prescriptions Transmit prescriptions electronically Conduct safety checks Drug information, Inappropriate dose, Inappropriate route. Drug-to-drug interaction, Allergy concerns, Warnings/cautions Provide information on lower cost alternatives Provide 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 the
New Era of EMRs, eHealth, ePrescribing – and beyond Claudia Tessier LLC

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

Learning Objectives 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.

Ethics Matters 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.

Quality in Healthcare Technical Quality Service Quality Ethics Quality

Levels of Ethics Quality
Decisions and actions Systems and processes Environment and culture Decisions and actions Systems and processes Environment and culture

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

Preventive Ethics 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

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

What is the ISSUE? The process involves six steps: Identify Study
Select Undertake Evaluate Sustain

IDENTIFY an 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.

Patient Concerns The use of electronic medical records and the confidentiality of medical records. Access to the computerized patient record system.

STUDY the Issue Diagram the process Gather data about best practices
Gather data current practices Refine the improvement goal

The issue selected as a priority by the Preventive Ethics Team
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.

Diagram the process behind the relevant practice
Patient Generated Address Phone number Next of kin Date of birth Marital status Gender Religion Eligibility Military service Service connection Medical history Sensitive record Healthcare Team Generated Appointments Allergies Vitals Medications Appointment Consults Inpatient stays Lab Mental Health visits Oncology reports Pathology reports Outpatient visits

Best Practices 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.

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

SELECT a Strategy 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.

Major Cause(s) of the Ethics Quality Gap

Strategies to Narrow the 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.

UNDERTAKE a Plan 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.

Our 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.

EVALUATE and Adjust Check the results Adjust as necessary
Evaluate the ISSUES process

Identified Barriers 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.

Solutions 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.

SUSTAIN and Spread Integrate the change into standard operating procedures. Disseminate the improvement. Continue monitoring.

Monitoring tools Customer service surveys
Annual SHEP (inpatient and outpatient) report Self reported patient complaints Patient advocate feedback

Other ISSUES approaches
MRSA testing post mortem. Conflicting patient and provider expectations. Assessing decision making capacity. Do all patient with dementia lack decision making capacity?

Conclusion From …… To …… Reactive Case based Narrow Silos Punishment
Rules To …… Proactive Systems oriented Comprehensive Collaboration Motivation Rules & Values

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

Medical Records Department Electronic medical records (EMR)

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