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: tung.nguyen@coremedicalsolutions.com

Phone: 0403 616 948

Website: www.coremedicalsolutions.com