Electronic Documentation: A New Direction for Healthcare Information

Presented by:

Alexandra Zuniga, R.P.T. Director of Rehabilitation Pan American Hospital

January 24, 2007 Florida International University Physical Therapy Program

Five Main Goals of Healthcare Information Systems:

Reduce medical errors and improve patient safety. Reduce duplication and waste. Promote patient-centered care. Give providers tools for better decision making. Eliminate handwritten clinical data by 2015.

Methodology for Choosing a Vendor

Pan American Hospitals leadership team analyzed fiscal, clinical, and functional needs. Seven vendors held presentations in a general forum and individual departmental presentations. CPSI was chosen based on enterprise wide software applications, ease of use, functionality and cost.

About CPSI: Corporate Development

Computer Programs & Systems Inc. (CPSI) has been serving the healthcare information needs of the medical community for over 25 years. Founded in 1979 and is headquartered in Mobile, Alabama. Provides a complete patient care information system from business office to bedside. In 2005, CPSI was rated #31 on Forbes 200 Best Small Companies.

About CPSI: System Product Development

CPSIs primary goal is to develop and support quality application software for a totally integrated system. Over 540 medical facilities nationwide are running the major application modules. Over 200 Critical Access hospital client facilities have undergone similar conversions.

About CPSI: Organizational Structure

Six major divisions Information Technology Services Financial Software Services Clinical Software Services Programming Services Administration Sales and Marketing

Clinical and Patient Care Applications

Electronic Medical Record (EMR) Point of Care (POC) Hospital Based Functions Computerized Physician Order Entry (CPOE) Picture Archiving and Communication System (PACS) Web Based Physician Access

Portability of Systems

Mobile Cart Station Wireless Laptop Tablets The wave of the future. Wireless Personal Data Assistant (PDA) Fingerprint Biometrics when signing on

Main Application Software

Clinical Modules

(Physical Therapy System)

(Enterprise Wide Scheduling) (Accounts Payable) (Archival Data Repository)

Enterprise Modules

Financial Management Modules

Miscellaneous Modules

Software Continued

Office Automation Modules

(ClientWare Networking)
(Order Entry Systems) (Care Plans) (Point of Care Systems) (Electronic Forms Module) (Electronic Claims Submission) (Digital Signature Capture)

Patient Care Modules

Patient Management Modules

Patient Management Modules

User Sign In

Registration/ADT

Provides timely, accurate information on the most critical aspects of hospital operations. Manages patient admission, status, room changes, charges, and discharge. From pre-admission to discharge, keeps patient information available to hospital staff. Demographic data is stored and can be transferred in the case of a re-admission.

Sample Face Sheet

Automated Registration Documentation System (ARDS)

Helps streamline registration tasks. Allows printing inpatient and outpatient forms without having to change printers or paper. Examples are face sheets and signature forms. Eliminates card embosser. Bar coded patient labels can be printed on a single sheet of paper and be placed on patient wristbands and documents.

Digital Signature Capture

Compact devices store secure and legally binding signature to any patient document. Reduces paper documents. Forms include Admission Forms, Treatment Authorizations, Release of Information, etc. Documents can include text, single or multiple signatures, hospital specific information and can automatically include demographic information. Integrity of signature is protected by requiring a new signature if the text is changed.

Health Information Services

Includes daily patient Census. Includes patient accounting modules for Diagnostic Related Groups (DRGs). This supports the quality assurance/quality control needs of insurance billing. Also provides additional statistical information.

Indexes and Functions Available

DRG Grouper and Reporting

Assigns DRGs from the diagnosis and procedure codes. Provides both concurrent and historical reports on the factors that affect reimbursement by DRG. Provides hospital Administration and Department Directors with the information necessary for effective hospital management.

Master Patient Index

It allows patient information to be unitized and arranged in serial numbering systems. It provides immediate access to patient financial and medical data associated with a patient stay.

Sample Patient Index

Chart Location/History Tracking

Allows the user to update and review the patients medical record. You can search for a patient chart on-line using the account number by performing a numeric look up or by patient name through alpha look up.

Point of Care Menu

To search for a patients chart

Using patient name

Using patient account number..

Sample Patient Chart

Document Scanning

Documents like patients drivers license, insurance cards, patient transfer orders etc. can be scanned and stored electronically. Scanned documents are available immediately to authorized users and can be printed. If used with the Archival Data Repository, this can permanently include any document in the patients historical records.

Electronic Claims Submissions

Provides computer to computer link with the Medicare intermediary to submit claims. This allows the hospital to have increased efficiency with its financial management.

Quality Improvement

CPSI provides modules that can assist the user in completing functions necessary for Quality Assurance, Risk Management, Utilization Review, Physician Credentialing and Infection Control. The hospital can change the system parameters to meet its needs.

Managed Care

This system can track various insurance plans and the patients that are enrolled in them. This information is stored during the registration process. Payment terms can be set up. An unlimited number of healthcare networks may be created.

Patient Care Module

Order Entry System

Effective alternative to written tickets. Eliminates mistakes due to illegibility. Establishes controls for accountability. The Rehab Department at Pan American Hospital designed Order Entry categories by discipline with drop down menus.

Order Entry Menu

All Ancillary Departments

All Rehab Orders

Specific Order Selection

Sample Physical Therapy Order

ChartLink Computerized Physician Order Entry (CPOE)

Benefits include decreasing medical errors which accounts between 44,000 and 98,000 deaths per year. Customized by Pan American Hospitals Medical Staff to fit their needs. Physicians underwent training with ChartLink Fair compliance due to resistance to change.

CPOE Continued.
Medication Order Entry

Allows physicians to order medications and set administration frequency and duration parameters. The application is fully integrated with the patients current clinical and demographic information. Alerts can be set up to prevent adverse drug interactions and/or duplicate therapies.

CPOE Continued.

Ancillary Order Entry Allows physicians to order ancillary tests and therapies. Includes Rehabilitation orders for Physical and Occupational Therapy, Speech Language Pathology and Orthopedic Technician services. Can add additional pertinent information in comment section such as weight bearing status.

Electronic Forms Module

Electronic forms replaced paper forms. Forms are customized to needs and standards. The Rehab department created forms using existing forms and Medicare guidelines to assist in familiarity during the conversion. The on-screen forms look like the forms they replaced. Includes an anatomical diagram image feature useful when documenting wound care.

Flowcharts.

Sample P.T. Evaluation

Narrative Information.

Sample of Anatomical Diagram

Clinical Module

Benefits of the Physical Therapy Module

Timely and accurate clinical information. Maintains a journal of daily orders through the Order Entry system which helps us communicate with Nursing and Medical Staff. Allows department to receive orders from any designated location. Maintains technical, statistical and patient account information. Improves overall efficiency.

Medication Verification System

Medication Verification

The medication order can be placed by a Physician through ChartLink (CPOE) or through Pharmacy using Order Entry. The medication is pre-screened by a monitoring Pharmacy module for possible allergies and/or drug interactions. Final check is done at time of administration by scanning patients label using barcode verification.

Sample Allergy/Duplicate Medication Checks

Medication Verification Continued...

Two bar codes one on patient wristband and one on medication that identifies individual medication and dosage. The system compares the information from both scans to the medication profile of outstanding orders to assure a match-up. If there is no match up, the system sends alert to prevent a potential medical error.

Office Automation Module

ClientWare Networking

Able to view on-line documentation to perform chart reviews for current and discharged patients. Able to answer any Physician or Discharge Planning questions from desk. Able to view live Order Entry lists to check if orders have been sent for a specific patient and discipline.

Extra Features

Financial Information and account information Insurance claims processing Enterprise wide scheduling

Summary

Hospital wide system that communicates across all departments. Covers clinical, demographic and financial information. Electronic documentation decreases medical errors. Stores information from past patient stays for easy reference. Easy to use, easy to review. LEGIBLE!!!!

Q&A

THANK YOU