PDOC Transition Handbook. Meditech

Transcription

1 PDOC Transition Handbook Meditech Prepared by Kootenai Health Information Technology May 2013

2 Table of Contents Document Purpose... 2 PDOC Implementation and Training Plan... 3 Summary PDOC Transition Plan... 3 Summary PDOC Training Plan... 3 Template Management... 4 Change to Existing Established Templates... 4 Request for New template... 4 Optimization of New Templates... 4 Identified Patient Safety Concerns Related to a PDOC Template... 4 Feedback from New Users on Established Templates in Maintenance Phase... 4 Maintenance Review of Established Templates... 5 MIS Role... 6 Confirmation/Acceptance of Terms... 7 PDOC Request Guidelines... 8 Purpose... 8 Stakeholders... 8 Site Responsibilities... 8 Analyst Responsibilities... 9 Electronic Physician Documentation (PDOC) Acceptance of Terms... 11

3 Document Purpose This handbook has been created to outline the PDOC transition process and address the policies and procedures related to use of PDOC within the NIRHC by all potential end-users at Kootenai Health. Included are the expectations for use, requirements for creation and modification and several tools to accomplish those tasks. Individual hospitals may incorporate additional PDOC policies to be used in conjunction with this document. However, additional policies should compliment rather than contradict the policies set forth in this document. Page 2

4 PDOC Implementation and Training Plan Summary PDOC Transition Plan Any provider privileged to practice at Kootenai Health will have the option to document electronically in Meditech using PDOC. Information Services is committed to optimizing each provider s transition to PDOC. In order to ensure a successful adoption, the transition must be scheduled so that the IS team can allocate the proper resources. Training staff will work with the provider to identify a training time which is convenient for the provider. If the provider can use a template which already exists and has similar practice to other current PDOC users, training will be coordinated within one to four weeks, depending on the availability of IS resources. Summary PDOC Training Plan Training will be completed by the Information Services staff which may include any of the following: Chief Medical Information Officer (CMIO), clinical analysts and training staff. The anticipated time commitment for a new user is one hour. As a part of training, providers will be instructed to use note templates appropriate to their area of expertise and appropriate for the type of care they are providing. For example, a Progress Note template will not be used to document an H&P or initial Consultation. The Cardiology Progress note is to be used by cardiologists and not other specialists; the same is true for note templates for the Intensivists, surgeons etc. Provider may use the daily progress note template at any time, even if they have a template more specific to their respective specialties. New PDOC users will initially be trained on the Daily Progress note, Focused Progress Note, and Specialty Progress Note (e.g., Pulmonary Progress Note), if applicable, and Consultation templates. When proficiency is demonstrated, users may be advanced to use of the History and Physical and Discharge Summary with additional training/instruction required (approximately 15 minutes). A tracking sheet which includes the providers that have been trained, templates they have been trained on, and training dates will be maintained by the Informatics Office. The provider will provide contact information to the Informatics office for his/her first day of PDOC use. The Informatics office will provide support to the user on his/her first day of use via phone and in person, if preferred by the provider. Page 3

5 Template Management Change to Existing Established Templates This applies to Templates that are considered in Maintenance phase defined below. If changes to an existing template are desired, please refer to the PDOC request guidelines and Format for request PDOC. Request for New template If a request for a new template is desired, please refer to the PDOC request guidelines and Format for request PDOC. Optimization of New Templates Each specialty may have their own progress note template and when circumstances require it, a specific H&P template or Consultation note template may also be created. Initiation of a new template will require a formal request to be submitted to the CMIO. That request should represent the desired template with the included elements as agreed upon by all of those in that area of specialty. If assistance in coordination is required to achieve a consensus approval, the CMIO will assist in that process. Once a new template is initiated, it will be open for revision 1 month after launch and again at 3 months after those revisions are put in place then will be placed in the rotation with Maintenance of Established Templates, outlined below. If such significant modifications are requested that the anticipated number of analyst work hours required exceeds 10 hours the template launch would be considered a failure in which case consideration of complete removal of that template from the live system will need to be considered. Identified Patient Safety Concerns Related to a PDOC Template If a patient safety issue is identified that is created by a component or section of a PDOC note it will be up to the discretion of the CMIO and Informatics Staff to inactivate the functionality creating the concern and if necessary the entire PDOC template. All reasonable efforts to maintain the ability of a provider to document in PDOC will be pursued if patient safety can be maintained. Unless revisions are requested/required which impact patient safety the schedule for revisions/enhancements will be strictly followed to ensure the process continues to flow recognizing that with limited resources the process of bringing up additional users and templates will not be successful if there is not a formal process for revisions and corrections. Feedback from New Users on Established Templates in Maintenance Phase When a new provider is brought up on an existing template it will be necessary for them to complete approximately 25 notes in that template prior to submitting suggestions for enhancement/change. Those changes will need to be approved by all members of that specialty and should be discussed within that group prior to formal submission. The CMIO can provide coordination when necessary of the affected stakeholders. If several users are brought up around the same time the process to review potential enhancements will be completed when the majority of those new users are at or near 25 notes. Page 4

6 Maintenance Review of Established Templates All templates, once considered Established, will be placed on a yearly schedule for review at which time the effectiveness of that template will be reviewed, feedback from users will be sought and enhancements can be made. The formal governance process for standing review on this yearly schedule still requires further development. It is anticipated that a committee of Physicians will have general oversight of this process and will include specific provider involvement of current end-users for review of those templates that are specific to a practice area. For all template reviews a communication of upcoming review and request for feedback will be distributed to the current users on the Medical Staff to ensure that all end-users have an opportunity to provide feedback to the CMIO or Lead Physician Champion for PDOC for consideration. Page 5

7 MIS Role PDOC documentation will necessitate three Access Groups for Kootenai Health physicians: Nondocumenting, Documenting and KH PDOC Full Access (defined below), to be managed by MIS. Informatics will keep a list for providers and their designated access. Nondocumenting: Providers that do not have access to electronically document in Meditech Documenting: Providers which have been granted limited access to electronically document progress notes in Meditech. In general this will encompass physicians who have completed the first training session outlined above on the various progress note and consultation templates KH PDOC Full Access: Providers that have been granted full access to electronically document in Meditech If in the future development of additional Access Groups in MIS is required for appropriate maintenance and tracking of user templates, these will be considered. For example, it is expected that a new Access Group will be required at the time the ED Physicians initiate use of PDOC as this will streamline their workflow and ensure the appropriate template is available at the time it is needed for documentation in the EDM Module. Page 6

8 Confirmation/Acceptance of Terms A new provider will sign the Acceptance of Terms Form (included at the end of this document) at the time of training. This form indicates an understanding of the basic principles, expectations and requirements associated with the use of PDOC. This form will be maintained in the providers file in Medical Staff. This form is directed at the understanding of PDOC policy as it relates to Template Use and Management by the Informatics Office as well serving as documentation of their access group in MIS and current templates authorized/trained to use. There may be additional Medical Staff Bylaws and Policies Page 7

9 PDOC Request Guidelines Purpose These guidelines have been established to assist with the process of submitting a request for a new template or enhancement to an existing template. The steps have been outlined to ensure that stakeholders are involved in the decision making, testing, validation of functionality and confirmation that specifications are met. It cannot be emphasized enough the importance of including stakeholders at each step of the process. This will help ensure the stakeholders are satisfied with the results. Stakeholders Stakeholders include users of the template or any consumer of the information electronically documented via the template in PDOC. The following are examples of stakeholders (this list is not all inclusive): 1. PDOC physicians 2. Next provider of care (Medical Staff, Nursing, Office Staff) 3. Medical Records 4. Coders Site Responsibilities Prior to Submission 1. Review the request with multiple stakeholders at individual facility and obtain feedback. 2. Use the feedback to develop the exact specifications. 3. Outline the specifications using the Excel tool provided. 4. Present the request to the stakeholders, and ensure it is designed as the stakeholders desire. 5. Communicate with the stakeholders that the enhancement is being submitted and the request will be reviewed by a clinical analyst. a. Many sections are shared between facilities and templates. b. Oftentimes enhancements will impact stakeholders at other facilities. If this is the case, stakeholders at other facilities will also have to agree with the request. If there are questions or clarification is needed at anytime in the submission process the stakeholders may be asked to provide clarification or input. Submission 1. Open Help Desk Ticket. 2. Provide a brief description of the request. 3. Attach specifications using the tool provided. Testing 1. Ensure the request is working as desired. Thoroughly test the enhancement using the testing tips and various scenarios and workflow variations. Testing should include stakeholders. 2. Parallel test the enhancement to ensure workflow is being tested. 3. If the documentation is reliant upon others documentation (auto-pull information), ensure that both are done by end users, so workflow and timing are mimicked. Please be aware that workflow can vary between providers and it is best to have multiple providers involved in entering information. Page 8

10 4. Below are some examples of what should be tested by sites and stakeholders. This is not an all-inclusive list. Special attention should be paid to workflow, as providers often practice differently. a. Document in each field b. Document in some fields c. Edit d. Undo e. Save in Draft, Pending and Signed status f. Document utilizing cosigning g. Document on one patient, then another h. Document on different registration statuses i. Document on existing and newly registered patients j. Validate EMR, ECHART, Interfaces etc 5. Communicate via the help desk ticket that testing has been completed and grant approval to make the changes in LIVE. 6. If requested from analyst, work with stakeholders regarding the best date and time to make the changes in LIVE. Training/Communication 1. Develop training and communication plan, involving stakeholders 2. Notify analyst of training and communication plan including dates, times and methods 3. Implement training and communication plan on the established dates and times Go LIVE 1. Confirm with Stakeholders that the enhancement is working as desired 2. Communicate with analyst via the help desk ticket if it is found that the enhancement is not working as desired 3. If needed, work with HIM and ensure that the new enhancements are correct in the ECHART Analyst Responsibilities Prior to Submission 1. Answer questions regarding what may or may not be technically possible 2. Brainstorm and provide alternate solutions Submission 1. Review the request, provide feedback and request clarification as needed 2. Facilitate communication of the requested enhancement to impacted sites. a. Actual communication to other sites may be done by the analyst or delegated to the site; this will be left to the discretion of the analyst 3. Complete enhancements in TEST 4. Communicate with facilities when enhancement is available in TEST 5. Proceed with CCRB documentation and submission process when appropriate Testing 1. Ensure it is working from a technical standpoint 2. Schedule a Go Live date and time with input from stakeholders that complies with normal change schedule Training/Communication Page 9

11 1. Assist sites with developing training materials, if requested. Go LIVE 1. Make enhancements in LIVE. 2. Communicate with sites once the enhancements are LIVE. 3. If possible, confirm the enhancement is working from a technical standpoint. 4. Complete help desk ticket. Page 10

12 Electronic Physician Documentation (PDOC) Acceptance of Terms I have received, reviewed and agree to comply with the PDOC Use Policy provided by Information Services, Clinical Informatics. I have received training on the templates listed below for use as needed within the scope of my inpatient clinical practice. New User Existing User Requesting Additional Template Access Template Date Signature: Date: Name (print): Title: Practice: Contact number: address: For Informatics use only: Training Scheduled Access changed in TEST Training Complete Access changed in LIVE EMR Access Group: MPA: Date for Go Live: Page 11