Post on 07-Apr-2018
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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
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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.
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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.
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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.
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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.
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About CPSI:
Organizational Structure
Six major divisions
Information Technology Services
Financial Software Services Clinical Software Services
Programming Services
Administration Sales and Marketing
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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
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Portability of Systems
Mobile Cart Station
Wireless Laptop Tablets
The wave of the future.Wireless Personal Data Assistant (PDA)
Fingerprint Biometrics when signing on
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Main Application Software
Clinical Modules
(Physical Therapy System)
Enterprise Modules
(Enterprise Wide Scheduling)
Financial Management Modules
(Accounts Payable)
Miscellaneous Modules
(Archival Data Repository)
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Software Continued
Office Automation Modules (ClientWare Networking)
Patient Care Modules (Order Entry Systems) (Care Plans)
(Point of Care Systems)
(Electronic Forms Module)
Patient Management Modules (Electronic Claims Submission)
(Digital Signature Capture)
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Patient ManagementModules
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User Sign In
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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.
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Sample Face Sheet
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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 asingle sheet of paper and be placed on patient
wristbands and documents.
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Digital Signature Capture
Compact devices store secure and legally bindingsignature to any patient document.
Reduces paper documents.
Forms include Admission Forms, TreatmentAuthorizations, Release of Information, etc.
Documents can include text, single or multiplesignatures, hospital specific information and can
automatically include demographic information. Integrity of signature is protected by requiring a new
signature if the text is changed.
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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 statisticalinformation.
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Indexes and Functions Available
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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.
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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.
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Sample Patient Index
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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.
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Point of Care Menu
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To search for a patients chart
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Using patient name
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Using patient account number..
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Sample Patient Chart
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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.
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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.
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Quality Improvement
CPSI provides modules that can assist the user
in completing functions necessary for Quality
Assurance, Risk Management, Utilization
Review, Physician Credentialing and InfectionControl.
The hospital can change the system parameters
to meet its needs.
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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.
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Patient Care Module
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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.
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Order Entry Menu
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All Ancillary Departments
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All Rehab Orders
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Specific Order Selection
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Sample Physical Therapy Order
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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.
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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 druginteractions and/or duplicate therapies.
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CPOE Continued.
Ancillary Order Entry
Allows physicians to order ancillary tests andtherapies.
Includes Rehabilitation orders for Physical andOccupational Therapy, Speech LanguagePathology and Orthopedic Technician services.
Can add additional pertinent information incomment section such as weight bearingstatus.
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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 toassist 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.
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Flowcharts.
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Sample P.T. Evaluation
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Narrative Information.
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Sample of Anatomical Diagram
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Clinical Module
B fi f h Ph i l Th
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Benefits of the Physical Therapy
Module
Timely and accurate clinical information.
Maintains a journal of daily orders through theOrder Entry system which helps us
communicate with Nursing and Medical Staff. Allows department to receive orders from any
designated location.
Maintains technical, statistical and patientaccount information.
Improves overall efficiency.
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Medication VerificationSystem
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Medication Verification
The medication order can be placed by aPhysician through ChartLink (CPOE) orthrough Pharmacy using Order Entry.
The medication is pre-screened by amonitoring Pharmacy module for possibleallergies and/or drug interactions.
Final check is done at time of administrationby scanning patients label using barcodeverification.
S l All /D li t
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Sample Allergy/Duplicate
Medication Checks
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Medication Verification Continued...
Two bar codesone 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 alertto prevent a potential medical error.
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Office Automation Module
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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 patientand discipline.
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Extra Features
Financial Information and account information
Insurance claims processing
Enterprise wide scheduling
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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!!!!
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Q & A
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THANK YOU