Direct Data Entry e-Forms: the bridge between scanned records and the
paperless hospital
Tung Nguyen BHIM/BHS (LaTrobe)
BOSSnet Victorian Account Manager
Agenda
• Introduction
• The current situation: Paper based forms in a scanned record
• The solution: Electronic Forms
• Why use e-Forms?
- Issues
- Aspirations & reality
- Costs & Benefits
• Key messages
•Transcription requirements (simple versus complex)
• Key messages
• General discussion and questions
Introduction – who am I?
• Health Information Manager.
• Worked across four tertiary health services that have implemented a scanned medical record solution.
• Currently managing a Digital Medical Record.
• Used to record diary-like statements of work and treatment outcomes for clinicians.
• Recognised issues with timely access (scanning backlogs), storage and retrieval.
• Need to document the same data in multiple times on multiple forms.
• Limited ability to collect and share data in a standardised format.
•Readability issues of handwritten forms.
The current situation: Paper forms in a scanned record
The solution: Electronic Forms
• Data collection tools.
• Input can be simple (e.g. free text and drop down boxes) or complex (e.g. abstracted from other clinical tools and systems).
• Have the ability to output the data in various ways to assist clinical care (e.g. graph points on a growth charts).
• Enable point in time data collection.
Issues & Considerations
• Change management
- attitudes & behaviours
- Planning
• Identify workflows that do not currently exist.
• Start with small steps (e.g. simple transcription e-Forms in a targeted department).
• Consider adopting shared terminologies and concepts (e.g. ICD-10-AM).
• Work towards reducing and eliminating the issues caused with written forms.
Costs
• A clinical system needs to be in place to support e-Forms.
• Sufficient availability of clinical access devices.
- Clinical drive for mobile devices due to advancements in technology (e.g. smart phones and iPads).
• Clinical buy-in from stakeholders.
•Operational and ongoing support.
Benefits
• Improve data readability (for accurate diagnoses, referrals, assessments, care plans etc).
• Collect standarised data to improve service quality through research, billing and State/Federal minimum data sets.
• Instant storage and access to patient data in real time (no delays in scanning).
• Linkage to clinical systems, protocols for decision support.
• Enables data to be manipulated and displayed in different formats.
• You are in control of the data.
The reality of using e-Forms
• Changes to attitudes and workflows take time, however there is a great push from clinical teams to implement direct data entry e-Forms .
• Health services must ensure the demand for e-Forms is met with the supply of sufficient clinical access devices.
• Requires buy in from all stakeholders.
• Requires process/work flow redesign.
Simple e-Forms•Examples include:
- Admission forms
- Coding sheet
- Questionaires
•Used to tidy up existing paper forms.
•Allow clinicians to ease into the change from hand writing to direct data entry.
•Immediate benefits seen.
Complex e-Forms
• Examples include:
- Discharge Summaries
- Progress Notes
- Growth Charts
• Should integrate with other tools to provide a complete picture of episode of care.
- Medication Management (allergies and contraindications)
- Results (Pathology & Radiology)
- Pharmacy (inventories)
• Provide clinical decision support.
Summary
• The ultimate goal for a clinical environment should be paperless.
• Change requires time and planning.
• Consider the use of standardised terminologies and concepts.
• E-Forms should be able to share data with other clinical systems and tools.
Tung Nguyen BHIM/BHS (LaTrobe)
BOSSnet Victorian Account Manager
Email: [email protected]
Phone: 0403 616 948
Website: www.coremedicalsolutions.com