From Paper to Data.. Changing Roles and Functions

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From Paper to Data..Changing Roles and Functions
THE CHANGING APPROACH TO OVERSIGHT OF CLINICAL
RECORDS IN THE ERA OF COMPUTERIZATION

• California Information Management Conference
• Diane Premeau MBA, RHIA, CHP
• April 11-12

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Current Functions in Clinical Record Oversight

• Locate, Retrieve and Deliver Record
• Validate Record is for Correct Client
• Verify documents are in the correct folder
• Assure all documents are complete
• Notify clinician of inconsistencies in record
• Correct record within scope of practice

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Validate Record for Correct PatientVerify
Documents in Correct Folder, Admission

• PAPER Check consent signatures, age,
  diagnoses
• If wrong client, remove documents and determine
  correct location
• DATA Create and run reports for client
• Identify inconsistencies between previous
  documents, birth dates, diagnoses.
• In conjunction with IT, identify documents in
  wrong client record and follow procedure to
  correct record (options may include - move to
  correct location, move to unviewable location or
  notify clinician of inconsistencies for review
  and advisement)
• Example Client admitted for mulitple services
  WRAP documentation identified as being created in
  Outpatient location.

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1-2-3 Start Writing Reports

• The Power of E-HR/Point of Care Systems is in
  Quality Monitoring from the DESK TOP
• Reports written to assist staff
• Diagnosis Profile of Each Client/Patient
• Monitoring Medications
• Evaluate referral source vs. outcome
• Monitor completion timelines for assessments,
  MSA, treatment plans
• Structured Progress notes linking service
  function with documentation requirements.

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ASSURE ALL DOCUMENTS ARE COMPLETE

• PAPER Assemble and analyze record for all
  documentation, signatures, dates, etc.
• Send letter to notify clinician of required
  documents for example Signature, dates,
  discharge summaries, diagnoses, etc.
• Clinician comes to department to correct record
• DATA Run reports for documents in draft, on
  hold, incomplete
• Notify clinician of documents pending completion.
• Send email or alert (depending on system)
• Send a copy of a report showing documents and
  status
• Re-run report to verify document complete

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NEW ROLES AND FUNCTIONS

• SYSTEM ACCESS In conjunction with Information
  Systems
• Provide Support and Training for Access to
  systems that includes
• Dictation System Electronic Signature
• Viewing documents in multiple systems
• Validate that System and E-Sign agreements are
  completed and filed with Credentialing office
• Notify IT/IS if clinician no longer at
  organization.
• Observe for unusual patterns of record
  completion
• ie. Documentation completed when clinician is
  not available
• Assist External Users (auditors) with access
  level and system login process.

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Monitoring Data Use

• Assist IS/IT in monitoring of external data
  requirements
• Assure that data is transferred at minimum
  necessary
• Log Data Use Agreements
• Log and Track release of data
• (same function as release of information (paper))
• Represent Data in Court

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Sample Auditing Monitoring Documentation
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Getting StartedChanges in Forms Management

• PAPER
• Forms created in draft format
• Evaluated against regulatory requirements
• Printedchallenges with version management
• Paper retrieved, completed and filed.
• DATA
• Recommend data elements
• Identify what type of reporting will be used
• Create a screen design output design from data
  capture
• Determine how to capture data elements (client
  level, episode level, document level).

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Forms- Behind the Scenes
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NOW WHAT??

• Increase number of data elements
• Validate all significant data elements captured
• Merge Documents from other systems???
• Incorporate information from anothers system
• MORE REPORTS MORE INFORMATION!

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QUESTIONS???

• diane.premeau_at_hhs.co.santa-clara.ca.us