The Transition From Paper To Electronic Patient Records

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The Transition From Paper To Electronic Patient
Records
The Coding Experience!!
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A Historical Perspective- Your Local Coding
Office!
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Previous Coding Process

• Collection of notes from wards and departments
• Extracting information from case notes
• Assigning codes
• Returning case notes to wards department

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Problems with the Previous Process

• Difficulty in obtaining the case notes for coding
  e.g. lost, unavailable
• Difficulty in reading hand writing of clinicians
• Poor filing within the case notes
• Time taken in finding and coding the information
  was the cause for the high numbers of uncoded
  episodes

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How the New Process was Developed

• Use the electronic system as a case note
• Discussion with clinicians regarding the
  information required
• Designed in house reporting system to support
  process

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Benefits of New Process

• Increased efficiency
• Availability of a pick list of diagnoses and
  procedures with codes for clinicians, which
  increases consistency
• Legible for all to read
• Easy to find information

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Source Data
The Trust has 1 area still using case notes and
Proformas but will be moving across during the
summer months and 1 other area which is still
using proformas until new PC equipment is
installed
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Comparison of Figures - Before After the New
Process
Figures from 15/5/2006
Figures from 22/05/2007
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Coder / Consultant Contact

• Increased in 2 ways
• The request for further information
• The sign off of the coding data

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Further Information Request

• Where a coder is unable to assign codes for the
  patient care then he/she sends an emailed request
  to the clinician for the information

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Sign Off of Coding Data

• This is done to ensure that the coding reflects
  what has happened to the patient during the
  inpatient stay
• This can be done in 2 ways
• Either by email to the consultant
• Or within a specially set up meeting between the
  clinician and the coder

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Selecting All Patients runs the Weekly
discharge Report displaying basic information
about each patients visit
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Training of Clinicians for the New Process

• The EPR training team contacted each person
  within each specialty who required training and
  set up 11 or group sessions.
• The EPR trainers also dropped into the wards to
  check training needs
• An EPR trainer attended some directorate meetings
  to demonstrate the process for entering
  information

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Training for Coders

• We have an in house Trainer who is TAP approved
  and ACC qualified
• Coders have the opportunity to study towards
• The ACC
• A Degree in Health Informatics

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Long Term

• Improvement in the quality of the information
• Improvement in the quality of coding
• Introduction of the new version of Snomed-CT

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Role of the Consultant

• This has now changed to accommodate the new
  process in that they are much more aware of the
  need for coding and have direct contact with the
  coder

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Role of the Coder

• Has changed to become more of an adviser to the
  consultants regarding the information required
• Give guidance regarding the rules and conventions
  which govern clinical coding
• Are akin to auditors with regards to data quality

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Benefits to the Coder

• Access to the consultant to ask questions
• Legibility of records eliminates confusion
• Quickness of accessing the information
• More time spent coding than find the information
• Multiple user access to the same patient record
  whilst in different areas enables discussion via
  telephone/email regarding the information

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Problems First Encountered

• Mixed level of support with regards the move from
  paper to electronic
• Lack of equipment
• Differences between specialities in working
  practice
• Difficulties meeting with consultants, e.g. not
  attending, dragging their feet about change
• General distrust of change in working practice

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Problems Resolved by -

• Discussion with consultants, service managers
  regarding the changes
• Training provided
• Installation of new equipment across the Trust
• Laptops with carts 115
• PCs - 112
• Support from the Trust Board and clinical
  directors
• Allow flexible entry of information
• Consultant, Lead nurses, Secretaries and Coders
  in Theatres

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Auditor Within the Department

• There is a full time Auditor based within the
  coding department who carries out audits of
  individual coders and of the information provided
  by the clinicians

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Coders in Theatres

• There are 3 coders based within the operating
  theatres to assist the clinicians in entering the
  correct operation information to allow high
  quality coding

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Dont Let This Happen To You!
The Department That Time Forgot!