Electronic Medical Record Update

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Electronic Medical Record Update

  1. 1. <ul><li>MUSC </li></ul><ul><li>Electronic Medical Record Update </li></ul><ul><li>October 2004 </li></ul>
  2. 2. Clinical System Initiatives <ul><li>PMSI/Practice Partner Overview and Status </li></ul><ul><li>Other Clinical System Initiatives </li></ul><ul><li>Information Technology Governance Structure </li></ul>
  3. 3. PMSI/Practice Partner Features <ul><li>Goal: Paperless outpatient chart. </li></ul><ul><li>Types of entry functions: </li></ul><ul><ul><li>Vitals, problem list, allergies </li></ul></ul><ul><ul><li>Phone requests documented </li></ul></ul><ul><ul><li>Meds/prescription (and re-fill) writer </li></ul></ul><ul><ul><li>Clinic notes (can be transcribed or entered via ‘point and click’ templates) </li></ul></ul><ul><ul><li>Scanning capability (referring or lose documents) </li></ul></ul><ul><li>Other types of data available </li></ul><ul><ul><li>Lab and radiology results </li></ul></ul><ul><ul><li>Hospital transcription such as Discharge Summaries and Operative Reports </li></ul></ul>
  4. 4. Practice Partner Implementation Objectives <ul><li>Enhance patient safety (e.g., PP has a prescription writing tool that has drug interaction and allergy checking features). </li></ul><ul><li>Improve documentation quality in order to better address regulatory, legal, and MUSC guidelines. </li></ul><ul><li>Improve coordination of care via secure electronic storage of clinical documentation such as vital signs, clinic notes, medications, problem lists, allergies, and phone calls. </li></ul><ul><li>Enhance revenue by improved workflow efficiencies , decreased turnaround time for documentation and availability of clinical documentation for billing purposes. </li></ul><ul><li>Reduce the costs of medical records storage, filing space, transcription costs and records management. </li></ul><ul><li>Decrease time spent with call backs from patients and pharmacies. </li></ul>
  5. 5. Practice Partner – Transcription Options <ul><li>Dictation options: </li></ul><ul><ul><li>Transcriptionist can type directly into PP, after selecting the patient in PP. The Word processing function within PP* has spell check and allows for templates to be built (e.g., standard headings, sections, etc.). This PP tool also allows for easy import of meds lists and other data into the note that is available within PP (and vice-versa). </li></ul></ul><ul><ul><li>Transcriptionist types in MS/Word (with some required standard codes at the top of the Word document) - and then imports these documents into PP and selecting a note import function. This import can be done in ‘batches.’ </li></ul></ul><ul><li>Physician direct entry options: </li></ul><ul><ul><li>Physician types directly into PP* using the word processing function as described in 1A above. </li></ul></ul><ul><ul><li>Physician enters notes via pre-formatted templates that are typically developed for the type of diagnosis or type of visit. Each specialty usually creates/refines these templates over time. </li></ul></ul><ul><li>*Note: PP does not currently have bold, italics, etc. capabilities in the current version, but a new version that has these features will be implemented by the end of 2004 . </li></ul>
  6. 6. PMSI’s Practice Partner (PP) system Status/Plans <ul><li>Goal: 330 ‘attending’ physicians on PP by end of 2005*. </li></ul><ul><ul><li>*For each physician, there are many additional users that are activated (e.g., nurses, COM staff, billing personnel). </li></ul></ul><ul><ul><li>Approx. 120 physicians currently using PP. </li></ul></ul><ul><ul><li>Approx. 50 in process (beginning with nurses) thru 12/31/2004. </li></ul></ul><ul><ul><li>Remaining 160 physicians to be implemented in 2005. </li></ul></ul><ul><li>Two Oracle data bases to be merged into one (November) </li></ul><ul><li>System/server redundancy planned for December. </li></ul><ul><li>Supported by Ambulatory IS team led by Jim Smith (5 FTEs). </li></ul>
  7. 7. Practice Partner Current Status <ul><li>Currently Utilizing Practice Partner </li></ul><ul><li>Family Medicine 23 </li></ul><ul><li>Endocrinology 18 </li></ul><ul><li>Internal Medicine (partial) 27 </li></ul><ul><li>Neurosurgery 5 </li></ul><ul><li>OB/GYN 27 </li></ul><ul><li>General Pediatrics 10 </li></ul><ul><li>Pediatrics (others) 10 </li></ul><ul><li>Plastic Surgery 4 </li></ul><ul><li> 124 </li></ul><ul><li>In Process </li></ul><ul><li>Neurology 13 </li></ul><ul><li>Rheumatology 8 </li></ul><ul><li>Ortho – adult 11 </li></ul><ul><li>Pulmonary 13 </li></ul><ul><li>Peds surgery 2 </li></ul><ul><li>47 </li></ul>
  8. 8. Practice Partner Rollout Plan <ul><li>2005 Rollout (yet to be scheduled) </li></ul><ul><li>Cardiology 22 </li></ul><ul><li>Dermatology 6 </li></ul><ul><li>HemOnc 14 </li></ul><ul><li>Infectious Diseases 6 </li></ul><ul><li>ENT 19 </li></ul><ul><li>Nephrology 15 </li></ul><ul><li>Ophthalmology 17 </li></ul><ul><li>Peds Adolescent Med 2 </li></ul><ul><li>Peds Cardiology 11 </li></ul><ul><li>Peds HemOnc 4 </li></ul><ul><li>Peds Nephrology 2 </li></ul><ul><li>Peds Neonatology 11 </li></ul><ul><li>Peds Pulmonary 4 </li></ul><ul><li>Surgery 22 </li></ul><ul><li>Urology 6 </li></ul><ul><li>Total 2005 161 </li></ul>
  9. 9. Other Clinical System Initiatives <ul><li>Advanced Point of Care Clinical System (RFP…) </li></ul><ul><li>OR system replacement </li></ul><ul><ul><li>Reinitiated in July (i.e., vendor selection to replace SurgiServe). </li></ul></ul><ul><ul><li>Site visits in progress. </li></ul></ul><ul><li>Transplant system </li></ul><ul><ul><li>Reinitiated in May (RFP process...). </li></ul></ul><ul><ul><li>Intent to award to be announced this week. </li></ul></ul><ul><li>‘ C3’ project (Oacis) </li></ul><ul><ul><li>Computerized Clinical Charting (C3). </li></ul></ul><ul><ul><li>Pilot for inpatient nursing documentation on wireless (laptop!?) LYNX DAL COWs – scheduled for mid November. </li></ul></ul><ul><ul><li>Web front-end to Oacis in early 2005. </li></ul></ul>
  10. 10. IT Governance Committees
  11. 11. OCIO Team

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