Creating a single point of access for your medical records

Transcription

1 Creating a single point of access for your medical records The Royal North Shore Hospital journey of discovery! Presentation to HIMAA Conference 30 October 2012 Marriott Hotel Surfers Paradise Prepared by Margie Luke Document Imaging Program Manager Northern Sydney Local Health District

2 Scope Royal North Shore Hospital Community Health Centre Pathology Sendaways

3 Background Benefits Actions Discoveries Overview Top 10 Lessons Learnt Results Way Forward

4 Background Drivers the case for change Minimal storage provision due to $1.25B redevelopment NSLHD vision for a digital facility Escalating costs for offsite storage & retrieval Management of CHC records a major issue

5 Benefits Clinical & Administrative Increases value of emr by providing immediate/secure multi-user access Logical filing via the ESH Minimum training required Medical records are never lost or damaged! Facilitates coding remotely

6 The Document Imaging Process

7 Event Sets

8 Establishing the Project

9 Governance Sponsor: GM RNS/Ryde Hospitals Chair: Director Corporate Governance Co chair: Clinical Engagement Manager Secretariat: DI Program Manager RNS Redevelopment Executive Committee Document Imaging Implementation Steering Committee Document Imaging IM&T Technical Reference Group

10 Committee Structures RNS Redevelopment Executive Committee Document Imaging Implementation Steering Committee (monthly) RNS Health Information Services Operational User Group (HIS OUG) (Redevelopment) Technical Reference Group (fortnightly) Document Imaging Project Implementation Committee (weekly) Event Set Hierarchy Patient Label Working Group Working Group Other Ad Hoc Working Groups Project Team (weekly)

11 Actions Working Group to design ESH Forms stocktake, catalogue & bar coding Change management BPR Communications Plan Training & Education Plan

12 Discoveries Event Set Hierarchy Working Group established Consultation across the LHD Consensus on ESH Assign all barcoded forms to the ESH ESH built into the emr

13 Our Event Set Hierarchy ESH folders created on emr for scanned document ESH Primary Event Set Admission & Registration Alerts & Adverse Events Assessment Documents Care Plans Certificates/Notifications Charts Consent Correspondence Diagnostic Results Discharge Documents ED Documents Interventions/Procedures Medication Documents Medico-legal Progress Notes Scanned Referral & Requests Barcode ID associated to an ESH folder Barcode ID format REG99999 ALT99999 AST99999 CPL99999 CRT99999 CHT99999 CON99999 COR99999 DIA99999 TRA99999 EMY99999 INT99999 MED99999 MLD99999 PRO99999 REF99999

14 Event Set Hierarchy Barcode ID Catalogue Number

15 Forms Discoveries Over 1K forms discovered (>50% unapproved) 100% local forms to bar code & template Only state forms (18%) bar coded Patient label No encounter bar code Unreadable MRN bar code

16 Discoveries Change Management Decisions Clinical & Administrative Business processes will change New policies, procedures & change registers Established focus groups, demonstrations, presentations & road shows

17 Communications

18 Communications

19 Discoveries Training Minimal training required for emr users Quick reference guide provided to all staff Community Health staff required full emr training Training courses established

20 Top 10 Lessons Learnt 1. Sponsorship & Governance 6. Communications Plan 2. Clinical Forms 7. Training Plan 3. Patient Label 8. Stakeholder Engagement 4. Change Management 9. Support Model 5. Manage competing priorities 10.Prioritise & keep smiling!

21 Results Throughput 100% Audit (first month one off) 10% Audit (monthly & ongoing) Error types

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25 (1.8%) 98.2% Accuracy 24

26 Way Forward Go live of services - timeline & deadlines Quality Assurance & Auditing Risk Management Design & Development of KPIs Ongoing Recruitment & FTE Arrangements Handover of DI to HIS as business as usual early 2013 Post Implementation Review (PIR) Moving on - Ryde Hospital in mid 2013

27 Thank you!