medicalrecords

8/8/2019 medicalrecords

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Who said this and When?

I am fain to sum up with an urgent appeal for adopting some uniform system of publishing the statistical records ofhospitals. There is a growing conviction that in all hospitals,even in those which are best conducted, there is a great andunnecessary waste of life In attempting to arrive at thetruth, I have applied everywhere for information, but inscarcely an instance have I been able to obtain hospitalrecords fit for any purposes of comparison If wisely used,these improved statistics would tell us more of the relative

value of particular operations and modes of treatment thanwe have means of ascertaining at present.


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Who and When

Florence Nightingale,Notes on Hospitals,

London: Longman, Green,Roberts, 1863


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MEDICAL RECORDS


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MEDICAL RECORDS

A medical record, health record, ormedical chart is asystematic documentation of a patient'smedical history and care. The term 'Medical record' is

used both for the physical folder for each individualpatient and for the body of information whichcomprises the total of each patient's health history.

.
http://en.wikipedia.org/wiki/Patienthttp://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Patient


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MEDICAL RECORDS

Medical records are intensely personal documents andthere are many ethical and legal issues surroundingthem such as the degree of third-party access and

appropriate storage and disposal
http://en.wikipedia.org/wiki/Ethicalhttp://en.wikipedia.org/wiki/Legalhttp://en.wikipedia.org/wiki/Legalhttp://en.wikipedia.org/wiki/Ethical


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MEDICAL RECORDS

Although medical records are traditionally compiled andstored by health care providers,personal health records maintained by individual

patients have become more popular in recent years.
http://en.wikipedia.org/wiki/Personal_health_recordhttp://en.wikipedia.org/wiki/Personal_health_record


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What is a health record?

A health record includes any information created by, oron behalf of, a health professional in connection withthe care of a patient


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Who are the Stakeholders

A medical record is property of the hospital, whereas the

data contained within the record is a privilegedcommunication in which patient has a vested interest.

If properly written, compiled, preserved and protectedfrom unauthorized inspection and disclosure, the

medical record benefits:Patients

Physicians

Healthcare Institute

Research Team

National and International Health agencies


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Who are the Stakeholders: indirect

Insurance companies

Workman compensation suits

Personal injury suits

Malpractice suits

Probate CasesNotification of births and deaths

Criminal cases

Certification

Identification of patients


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What format can a health record take?

A health record can cover a wide range of material:

Handwritten medical notes

Computerised records

Correspondence between health professionals

Laboratory reports

X-ray films and other imaging records

Photographs

Videos and other recordings

Audio recordingsPrintouts from monitoring equipment


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Record Lifecycle

Any record created by an individual, up to its disposal, is

a public record and subject to Information Requests

Create Use Store DisposalAnalyse

C

loseRecord


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Flow of Medical Record

Central Admission

Office

Wards

Medical Record

Department

1. Assembling

2. Admission. &

Discharge analysis

3. Storage Area

After completion of

Records

Hospital statistics prepared

Monthly/Yearly

Medical Record is filled for perusal

of Patients/claims/research

purposes.


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Purpose

Provide continuity of care to individual patients.

Basis for planning patient care.

Documenting communication between the health careprovider and any other health professional contributingto the patient's care.

Assisting in protecting the legal interest of the patient andthe health care providers responsible for the patient'scare.

.


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Purpose

Documenting the care and services provided to the patient

Serve as a document to educatemedical students/residentphysicians.

To provide data for internal hospital auditing andquality assurance, and to provide data for medicalresearch.
http://en.wikipedia.org/wiki/Educationhttp://en.wikipedia.org/wiki/Medical_schoolhttp://en.wikipedia.org/wiki/Medical_residencyhttp://en.wikipedia.org/wiki/Clinical_audithttp://en.wikipedia.org/wiki/Quality_controlhttp://en.wikipedia.org/wiki/Quality_controlhttp://en.wikipedia.org/wiki/Clinical_audithttp://en.wikipedia.org/wiki/Medical_residencyhttp://en.wikipedia.org/wiki/Medical_schoolhttp://en.wikipedia.org/wiki/Education


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SYSTEM OF MEDICAL RECORD

Medical Record of the patient stores the knowledgeconcerning the patient and his care. It containssufficient data written in sequence of occurrence ofevents to justify the diagnosis, treatment andoutcome.

In the modern age, Medical Record has its utilityand usefulness and is a very broad based indicatorof patients care.


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Traditionally, medical records have been written on paperand kept in folders.

These folders are typically divided into useful sections,with new information added to each section

chronologically as the patient experiences newmedical issues.

Active records are usually housed at the clinical site, butolder records (e.g., those of the deceased) are often

kept in separate facilities.


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The advent ofelectronic medical records has not only

changed the format of medical records but hasincreased accessibility of files.

The use of an individual dossier style medical record,where records are kept on each patient by name and

illness type originated at the Mayo Clinic out of adesire to simplify patient tracking and to allow formedical research.
http://en.wikipedia.org/wiki/Electronic_medical_recordhttp://en.wikipedia.org/wiki/Mayo_Clinichttp://en.wikipedia.org/wiki/Mayo_Clinichttp://en.wikipedia.org/wiki/Electronic_medical_record


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Content of the medical record

Vary depending upon specialty and location

Patient's identification information

Informed consent forms

Patient's health history (what the patient tells)Patient's medical examination findings (what the health-care providers observe when the patient is examined).
http://en.wikipedia.org/wiki/Medical_findingshttp://en.wikipedia.org/wiki/Medical_findings


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Content of the medical record

Other information may include

Lab test results

Medications prescribed

Referrals ordered to health-care providersEducational materials provided

Plans for further care

Patient instruction for self-care

Return visitsBilling information


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20

Contents of Medical Record

Diagnosis and plan of treatment

Follow-up care

Telephone calls

Discharge summaries

Patient records from other physicians


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The health record should be

Available in the right place at the right time to support

effective patient/doctor contact and to providecontinuity of care

Availability of the complete record when needed is a key

determinant of the performance of Health RecordServices


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Characteristics of full & accurate health records

Authentic Reliable

Complete & unaltered

Processes & systems have integrity

Useable Transferable

Structured


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Documentation

Key elements - accurate, complete, timely, legible

Source document - quality of the clinical record

Documentation errors - Main condition, otherdiagnoses, operations


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Documentation requirements

Do write:

Date and time of entriesPurpose of entry eg. admission note, planned review,

asked to see patient, end of shift reportHistory and examination findingsAssessment of current situationPlan for what needs to happen now and laterPrint name and sign, include position, contact details for

every entry

Use only approved abbreviationsComplete discharge summary and front sheet


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Documentation requirements

Dont write:

A repeat of clinical details previously written thiswastes yours and others time and wastes paper

Anything unpleasant, rude, or critical of either relatives,

patients or staffAnything that is not true or does not reflect reality

Backdated entries or changes to existing entries


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Documentation policy

Need to ensure there is a documentation policy in

place so clinical staff know the requirements fordocumentation and can be assessed against thoserequirements

See sample Guidelines for Medical Record andClinical documentation

What are the requirements for clinical documentation

in your country? Are these written in a policy? Doclinical staff know what they should be documenting?


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Ways of improving documentation

1. record design - well structured, standard order,

complete, cover the scope of the care

2. forms design - elicit information needed for patientcare and coding, easy to use, legible, designed inconjunction with health professionals who will usethem

3. education

clinicians - documentation is as much part of clinical

care as direct patient contactmanagement - channel resources and enthusiasm

into this area


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Quality of medical record documentation

Timely and accurate documentation is associated with:

Improved quality of care

Seamless continuity of care

Enhanced ability to demonstrate equitable delivery ofservice and improved outcomes

Streamlined work processes

Reduction in the duplication of work

Reliable data sources

Increased client, worker and payer satisfaction


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Assessment of documentation quality

Conduct a regular audit of documentation quality

Use standard data collection form can compareresults over time to determine improvements

Consider the data items that must be presented in adocumentation quality report and the format in whichthey should be recorded

See example of documentation audit sheet

f


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Process for a documentation audit

Select a random sample of 5% of discharges in a

given month, or at least 10 records (whichever is thehigher number) should be audited

Select records from a printout of the Medical Record

of all discharges in a month ordered by dischargedate. Select every 20th medical record number onlist for audit. If record selected is not available, thenext record on the list should be selected

The audit relates to documentation within theselected admission only


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Rules for Charting

Clarity, thoroughness, and precisionBlack or blue inkFirst initial, last name and titleNo empty space between chart entry and initial signatureDo not use ditto marksDo not erase or obliterate entryDraw a line through error, include correct information andthe word correction or corr next to entry


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Rules for Charting

Patients name on every page

Use present tense

Never chart for another person

Describe events or behaviorsBe specific as you can

Date and initial any corrections

Leave no blank lines

Use standard abbreviations


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Common Charting Mistakes to Avoid

Failure to record pertinent health or drug information

Failing to record nursing actionsFailing to record that medications have been givenRecording on the wrong chartFailing to document a discontinued medication

Failing to record drug reactions or changes in thepatients conditionTranscribing orders improperly or transcribing improper

orders


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Source-Oriented Medical Records

Traditional or conventional method used

Chronological set of notes for each visitIs difficult to follow or track specific problems

May be handwritten or transcribed in the chart


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Problem Oriented Medical Records

Problem list

Diagnostic and treatmentplan

Progress notes


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Medical records department

Functions as a part of central information services

Medical records committee

Medical records officer

assistant Medical record officer

Medical record technicians

Attendants/messengers/admission clerks


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Organization Chart by functions


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Organization chart by staff


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Staff requirement


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Department

layout

F ti f di l d d t t


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Functions of medical records department

Creation and Control of forms, registers

Daily receipt of case sheets pertaining to discharge fromvarious wards, there checking and assembly.

Daily compilation of Hospital census report.

Maintains & retrieval of records for patient care and

research study.Completion and Processing of Hospital statistics and

preparation on different periodical reports onmorbidity and mortality.

Online registration of vital events of Birth & DeathIssuing Birth & Death certificated up to one year.


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Functions of medical records department

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.


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International Coding of Diseases

ICD-10


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Introduction

For clinical coding to be as valuable as possible it iscritical the coder has:

access to a comprehensive and accurate medical

record, the skills to extract all pertinent data for coding, access to clinicians to ask questions and seek

clarification


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Sources of clinical data for coding

Morbidity coding is usually performed after the patient

has left the hospital

Information to be coded is abstracted from the wholemedical record

The coding process has two parts:

analysis of the medical record

allocation of correct codes

Responsibilities


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Responsibilities

Coders

reviewing the entire recordverifying the record contains appropriate

documentationcoding specifically and accurately the conditions or

diagnoses treated or affecting a patients carereferring the record to clinicians for clarification

Cliniciansrecording accurate and complete clinical

documentation in the medical recordrecording all diagnoses on the front summary sheetidentifying the main condition


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Abstraction of Relevant Data from Medical Record

1. Read the discharge summary or other correspondence

2. Compare any diagnosis in the discharge summary/letterwith that recorded as admission or provisional diagnosisand with that recorded on the front sheet

3. Read the history and physical examination

4. Read the front sheet of the relevant admission5. Identify relevant procedures

6. Review the entire record

7. Clarify information with the clinician if necessary

O


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When to consult with the Medical Officer

If conflicting, incomplete or ambiguous information isfound or if documentation is unclear

Check with the attending medical officer,the medical officer who filled in the front sheet

or the radiologist or pathologist

Coding should be a cooperative and collaborative effortbetween the clinician and the coder

Wh t t d ?


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What to code?

Main condition or principal diagnosis

+/- other or secondary conditions

+/- procedures, operations and interventions

S l ti th M i C diti M i Di i


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Selecting the Main Condition or Main Diagnosis

Consider those conditions which:

caused the patient to be admittedwere treated and/or investigated during the acute

admission

affected the treatment given and/or the length of stay

developed during the admission

The main diagnosis can then be selected from theseconditions

WHO d fi iti f i di i i diti


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WHO definition of main diagnosis or main condition

the diagnosis established at the end of the episode ofcare to be the condition primarily responsible for the

patient receiving treatment or being investigated

that condition that is determined to have been

mainly responsible for the episode of health care...

(ICD-10, volume 2, 4.4)

S d di i / Oth diti


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Secondary diagnosis / Other condition

l a diagnosis that either co-exists with the maindiagnosis at the time of admission, or which appears

during the episode of care

l complications and comorbidities

What is a comorbidity?


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What is a comorbidity?

A disease that accompanies the main diagnosis andrequires treatment and additional care, in addition to

the treatment provided for the condition for which thepatient was admitted

What is a complication?


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What is a complication?

A disease that appears during the episode of care, due toa pre-existing condition or arising as a result of thecare received by the patient

P bl ith d t i i th i di i


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Problems with determining the main diagnosis

absence of a clear-cut main diagnosis minor condition recorded as main diagnosis diagnosis recorded in general or ill-defined terms uncertainty of diagnosis

symptoms or signs listed as the main diagnosis no diagnosis recorded

Wh t i t di ?


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What is accurate coding?

each diagnosis must be assigned its correct code

(or codes) Codes should be as complete as possible all diagnoses affecting the care of the patient and

procedures performed during the episode of careshould be assigned codes

codes must be sequenced correctly with the maindiagnosis listed first

morbidity coding rules in volume 2 of ICD-10 shouldbe followed

To ensure accurate coding:


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Coders should be familiar:

with anatomy and physiology of the human bodywith medical terminology so that disease

descriptions can be interpreted into ICDlanguage

with disease processes and medical practice to beable to understand aetiology, pathology,symptoms, signs, diagnostic procedures, etc.



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Coders should also have:

an understanding of the content of the medical record

experience with the actual medical records so specificdetails can be located

detailed knowledge of the coding system being usedan understanding of data reporting requirements

Quality Assurance in Morbidity Data Collection


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Quality Assurance in Morbidity Data Collection

Increasing use of morbidity data leads to an increasing

concern for the reliability of data

Sources of error in MR information systems:

documentation of the patients care and condition

during the episode in hospital

coding the information in the medical record

processing the coded information

Coding accuracy


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Coding accuracy

Three dimensions of coding accuracy:

accuracy and completeness of individual codes

accuracy of the totality of codes to ensure they reflectall diagnoses treated; and

accuracy in the sequence in which the codes arerecorded, particularly in selection of the maincondition

Common sources of coding errors:


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Common sources of coding errors:

Clerical

careless mistakes, transposing numbersJudgmentalwrong subjective decisions taken

Knowledgemistakes due to lack of coder knowledge

Systematicerrors in the process of coding or problems with the

environment in which coders workDocumentation

incomplete, inaccurate, ambiguous, conflicting

illegible

What affects coding quality?


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Errors in the choice of code

Lack of feedback

Casemix number and type of cases to be coded

Use of coding conventions and coding rules

Lack of clarity in coding books

Changes in coding practice



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Documentation

Incomplete medical recordsAvailability of records

Coder/ clinician communication

Data entry

System edits

Forms design



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Workload

Education

Human resources

Environment

The individual

Reference material


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Why has communication traditionally been lacking?


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Why has communication traditionally been lacking?

lack of understanding of coding as a process and of

the importance of coded data clinicians do not feel a sense of ownership of the

classification system or the fact that the coded datareflect their work

coders feel intimidated about asking questions,seeking advice or asking about clinical issues

Ways of improving communication


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Ways of improving communication

encourage clinicians to attend coding meetings in

the clinical coding/medical record department request coders attend clinician meetings conducted

by each clinical specialty organise coding service to allow coders to

specialise clinician involvement in the development of coding

guidelines education for clinicians and coders

Five steps for quality control of coding:


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Five steps for quality control of coding:

establishment of objective criteria for coding quality

measurement of performance analysis of problems identified action taken to correct identified problems

review of performance after corrective action

Link to ICD-9


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Link to ICD 9

C:\Program

Files\Skyscape\Desktop\ICD-9-CM\ICD-9-CM.exe

Auditing
http://c/Program%20Files/Skyscape/Desktop/ICD-9-CM/ICD-9-CM.exehttp://c/Program%20Files/Skyscape/Desktop/ICD-9-CM/ICD-9-CM.exehttp://c/Program%20Files/Skyscape/Desktop/ICD-9-CM/ICD-9-CM.exehttp://c/Program%20Files/Skyscape/Desktop/ICD-9-CM/ICD-9-CM.exe


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g

To inspect and verify

To determine the degree of accuracy in ICD

coding based on coding rules and codingconventions


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Sample selection


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Sample selection

Period of audit

Audit sampleRandom sample

Target sample

Sample selection


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Sample selection

Random

Representative of morbidity database

Suitable for benchmarking

Only some records will have errors

Sample size recommended 5%Random number generator or table

Sample selection


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p

Target

Defined by coder-in-charge or auditor

Cases selected because of known or suspectederrors or difficult cases or because a new coderhas started work

Only some records will have errors

Retrieving and preparing clinical records


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Retrieve original record

Temporarily remove or obscure coded data

Recoding process


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g p

Coder B

Recodes each record

Assigns error categories if errors found tries todetermine what has caused the error

If there is a dispute, Coder C

Recodes each record

Assigns error categories

Coder C recoding


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Recodes record blind

Discusses code differences with Coder A andCoder B

Make final decision about correct codes

Assign errors to error categories

Examine and analyse results


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y

Need to develop a form for reporting of results

Scoring Tool formSummary Data form

The summary data forms the basis for a report aboutcoding quality and can be used to compare data atdifferent time periods.

Questions to ask when reviewing coding:


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Is the main diagnosis correctly identified?

Are all secondary diagnoses coded?Are all diagnoses coded?

Are all diagnoses and procedures coded correctly?

Have the codes been transcribed or data enteredcorrectly?

Coder competency is influenced by:


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p y y

Knowledge

SkillAttitude

Behaviour

Experience


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THE LEGAL ASPECTS OF MEDICAL CONFIDENTIALITY

LAW


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A duty of confidence arises when confidentialinformation comes to the knowledge of a person in

circumstances where he has notice, or is held to

have agreed, that the information is confidential, withthe effect that it would be just in all the

circumstances that he should be precluded from

disclosing the information to others.

1 OF 2


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THE EXCEPTIONS


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WHERE, ON MEDICAL GROUNDS, IT IS UNDESIRABLE TO

SEEK PATIENTS CONSENT, MAY DISCLOSEINFORMATION TO FAMILY OR CLOSE RELATIVE

WHERE DISCLOSURE TO THIRD PARTY WOULD BE IN THEBEST INTEREST OF THE PATIENT [EXCEPTIONALCIRCUMSTANCES ONLY]

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THE EXCEPTIONS


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WHERE IT IS IN THE PUBLIC INTEREST [EXCEPTIONALCIRCUMSTANCES ONLY]

WHERE IT IS NECESSARY FOR THE DOCTORS SELF-PROTECTION OR DEFENCE

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THE EXCEPTIONS


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WHERE A STATUTE REQUIRES DISCLOSURE

WHERE A COURT ORDERS DISCLOSURE

WHERE IT IS NECESSARY FOR PURPOSES OF APPROVED

MEDICAL RESEARCH

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THE PATIENTS BEST INTEREST


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DISCLOSURE TO FAMILY MEMBER OR CLOSE RELATIVE

ALLOWED WHERE PATIENT INCAPABLE OF MAKING

INFORMED DECISIONS ABOUT HIS OR HER OWN

TREATMENT

1 OF 4


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THE PATIENTS BEST INTEREST


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WHERE PATIENT IS IN A VULNERABLE STATEOF MENTAL HEALTH, EG. SUICICAL,DEPRESSION

IN SUCH CIRCUMSTANCES, DISCLOSURE TOPATIENT MAY PUT HIS LIFE/HEALTH OROTHERS AT RISK

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PARENT VS CHILD


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PARENTAL RIGHT DIMINISH AS THE CHILD ACQUIRES THEABILITY TO MAKE DECISIONS

PACE OF DEVELOPMENT WILL VARY FROM CHILD TO CHILD

PARENTAL RIGHT WILL TERMINATE WHEN THE CHILD HAS

SUFFICIENT UNDERSTANDING AND INTELLIGENCE

PARENT VS CHILD


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DOCTOR MUST ACT IN PATIENTS BEST INTEREST AND

MUST SATISFY HIMSELF THAT PATIENT HASSUFFICIENTLY MATURE UNDERSTANDING

DOCTOR MUST EXERCISE PROFESSIONAL JUDGMENT

DOCTOR MUST RESPECT PATIENTS CONFIDENTIALITY IFPATIENT SATIFIES THE TEST OF MATURITY

THE PUBLIC INTEREST


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DISCLOSURE MAY BE DESIRABLE AND APPROPRIATE TOPROTECT THE PUBLIC WHERE THE DOCTOR HAS REASONTO BELIEVE THAT PATIENTS MEDICAL CONDITION PUTSOTHERS AT RISK

THE PUBLIC INTEREST


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WHERE A CRIME HAS BEEN COMMITTED

WHERE A CRIME IS LIKELY TO BE COMMITTED

THE PUBLIC INTEREST


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WHERE THE PATIENT IS A CARRIER OF ANCOMMUNICABLE DISEASE

WHERE THE PATIENT HAS AN ILLNESS WHICH

MAY AFFECT MOTOR FUNCTIONS AND LEADTO LOSS OF SELF-CONTROL


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COMPULSION BY COURT ORDER


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MUST COMPLY STRICTLY WITH COURT ORDER

FAILURE TO COMPLY MAY LEAD TO CONTEMPTPROCEEDINGS

NO PRIVILEGE FROM DISCLOSURE OF CONFIDENTIALINFORMATION IN COURT PROCEEDINGS

SELF-PROTECTION


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IN DISCIPLINARY PROCEEDINGS, DOCTOR MAY DISCLOSECONFIDENTIAL INFORMATION ABOUT A PATIENT TO

DEFEND HIMSELF AGAINST PATIENTS COMPLAINT

PATIENT WHO MAKES COMPLAINT IS PRESUMED TO HAVEWAIVED CONFIDENTIALITY

CONSEQUENCES OF BREACH OF CONFIDENCE


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ACTION BROUGHT BY PATIENT FOR BREACH OF

CONFIDENCE

POSSIBLE REMEDIES IN CIVIL PROCEEDINGS

INJUNCTION TO RESTRAIN BREACH/ FUTURE BREACHES

DAMAGES IN LIEU OF INJUNCTION

CONSEQUENCES OF BREACH OF CONFIDENCE


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DISCIPLINARY PROCEEDINGS - COMPLAINT TO SMC

PROFESSIONAL MISCONDUCT IF DOCTOR DISCLOSESCONFIDENTIAL INFORMATION WITHOUT PATIENTSCONSENT, OR WITHOUT JUST CAUSE


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Authorization for release of information


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Record Maintenance


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Control record movement and location

Storage areas should be clean and tidy

Stores should be secure

Secondary storage for non-current records

Contingency/Business Continuity Plans

Scanning


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Scanning paper records can reduce storage requirements

However:

Costs of initial conversion

Consult with The National Archives

Protect the evidential value

Retention and Disposal Arrangements


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All organisations should have Record Retention and Disposal

policies to ensure records are annually selected for:

Secondary storage (eg off-site or scanned etc)

Permanent archival preservation

Destruction

Record Destruction


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Records must be destroyed in a secure environment

Contractors must abide by Confidentiality Agreements

Maintain a register of the destruction of records


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All The Reasons You ShouldIncorporate EMR into Your Practice


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Change requires a coalition of people who, throughposition, expertise, reputations, and relationships,

have the power to make change happen.

John P. Kotter in Leading Change

Use of Electronic Medical Records


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0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Portugal

France

Spain

United States

Greece

Ireland

Luxembourg

Italy

Belgium

Germany

Austria

Finland

United Kingdom

Denmark

Netherlands

Sweden

A Reality Check


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Our healthcare system is fragmented.care is delivered by a variety of

independent physicians, hospitals and other providers

Clinicians often take care of us without knowing previous treatmentsand by whomwhich can lead to treatments that are redundant,ineffective or dangerous

Vital data sit in paper-based records not easily accessed or combinedinto a integrated form to present a clear and complete picture of ourcare

Physicians spend an estimated 20-30% of their time searching for andorganizing information

Access to Patient Data


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Instant Access to Patient Data24/7 Access to Patient Data

Multiple Access to the Same Chart

An end to lost charts

No Waiting for Transcription to Come Back

Precise Documentation


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No more illegible handwriting

No loose paperDocumentation neat and orderly

Ability to update medications and problems lists at eachvisit

Exportation of OrdersImportation of Test Results


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Efficient Prescribing


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E-Scribing

No more calls from pharmacy cant read the doctorswriting

Ability to fax Rx refills directly to pharmacy, no more calls

Electronic drug interaction alerts

Ability to incorporate insurance formularies into EMRsystem

Instant Allergy Alerts

Enhances Productivity


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Instant Messaging

Electronic Work ListsLess Time Chasing Charts, More Time With

Patient/Patient Care

Instant Information

Patient Education Materials at Finger Tips


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Paper Record Versus EMR


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A patients age is not included in the medical record10% of the time

A diagnosis is not recorded in the patients record 40%of the time.

Physicians, while taking a medical history, fail to notethe chief complaint in the patients record 27% ofthe time.

Paper Record Versus EMR


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Physicians spend up to 38% of their time writing up patient charts.

Nurses spend up to 50% of their time writing up charts.

Medical records are misplaced or missing in 30% of patient visits.

The average patient visit generates 13 pieces of paper.

The average office spends $10 per visit to track and file paper records

The average patient record weighs 1.5 lbs.

Source: Committee on Improving the Patient Record, Institute of Medicine

Patient Benefits


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Clinicians receiving computerized patient symptom assessments prior to a patient visitaddressed 51% of their patients symptoms, compared with only 19% of those not

receiving assessments

63% of consumers in a February 2004 survey agreed it would be very valuable to havetheir complete medical history stored in one computer file that can be accessedanywhere in the hospital

Foundation for Accountability Survey found that Consumers believed that having health

information online would:Clarify doctor instructions 71%Prevent medical mistakes 65%Change the way they manage their health 60%Improve quality of care 54%

A Harris consumer interactive poll found that:

80% want personalized medical information on-line from their physicians69% want on-line charts fir tracking chronic conditions83% want to receive their lab tests on-line

Summary of EMR Benefits


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Decreased Billing

Errors

Increased Billing

Capture

Radiology

Savings

Lab Savings

Drug Savings

Adverse Drug

Events Prevention

Transcription

Savings

Chart Pull

Savings

Source: Partners Health Care experience based on 2500 patients and providers. Cost and Benefit Analysis for electronic medical

records in primary care. The American Journal of Medicine 2003;114:397-403

15%

14%

13%5%

5%

15%

29%

4%


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EMR Functionality


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Auto interface to hospital and ambulatory dictations

Web-Based Personal Health Records (PHRs), so that family can

review selected materials that physicians elect to provideelectronically o Health maintenance recording and tracking foroutcomes measurement

Integration with document imaging and workflow management

Clinical messaging between physicians and the staff

Clinical messaging between the physicians and the patients familiesfor selected activities

EMR Functionality


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Recording and tracking of telephone messages

Electronic Rx refills

Order tracking and alerting if a test result has not been completedwithin a specific period of time

Template-driven clinical charting, to ensure that chart clinicalinformation is complete and interoperable between specialists

Access anywhere, at anytime, on any device

Synchronization of records


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When care is provided at two different facilities, it may be difficult toupdate records at both locations in a co-ordinated fashion.

Two models have been used to satisfy this problem: acentralized data server solution, and a peer-to-peerfile synchronization program (as has been developed for otherpeer-to-peer networks).

Synchronization programs for distributed storage models, however,

are only useful once record standardization has occurred.

Merging of already existing public healthcare databases is a commonsoftware challenge. The ability of electronic health recordsystems to provide this function is a key benefit and can improvehealthcare delivery

Customization
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Each healthcare environment functions differently, often in significantways. It is difficult to create a "one-size-fits-all" EHR system.

An ideal EHR system will have record standardization but interfacesthat can be customized to each provider environment. Modularityin an EHR system facilitates this. Many EHR companies employvendors to provide customization.

This customization can often be done so that a physician's inputinterface closely mimics previously utilized paper forms.

Customization


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At the same time they reported negative effects in communication,increased overtime, and missing records when a non-customized

EMR system was utilized.[65] Customizing the software when itis released yields the highest benefits because it is adapted forthe users and tailored to workflows specific to the institution.

Customization can have its disadvantages. There is, of course,higher costs involved to implementation of a customized system

initially. More time must be spent by both the implementationteam and the healthcare provider to understand the workflowneeds.

Development and maintenance of these interfaces andcustomizations can also lead to higher software implementation

and maintenance costs.These hurdles make customizations that can be made publicly
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Disadvantages of electronic medical records


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Physicians do tend to see at least short-term decreasesin productivity as they implement an EHR. They spendmore time entering data into an empty EHR than theyused to spend updating a paper chart with a simpledictation.

Studies also call into question whether, in real life, EHRsimprove quality.

Patient register and appointment planner


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Patient register and appointment planner

Add Clinical data

Add Lab records and medical images

Enable Web based upload and access

Pool related data from a group

Use pooled data for retrospective study and plan prospective study


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The Incremental EMR


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Documents

medicalrecords