1 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 1 of 11 Quality Issues on Paper Based Medical Records and Challenges on Transition to Electronic Medical Records Author Ram B. Bhandari 1. EXECUTIVE SUMMARY During the past decade Holy Cross Hospital (HCH) is facing overwhelming challenges and quality issues in medical records department due to increasing number of patients resulting accumulation of decade long - paper base medical records. These patients records are loaded in the files some packed in boxes and some in rooms of draws where files are arranged according to the alphanumeric order. With everyday increase in number of new patients, it is just impossible for employees and hospital systems to manage the patients records which are considered very valuable to patients and hospitals. This further result into the quality issues when it comes down to customers, making it very difficult to get their medical records in a timely manner when needed. The second issue is about lengthy time results into poor patients (customer) service because it is very problematic for clinicians and doctors to have access when needed. The third quality issue is burden of keeping the records in files for many years where quality service is scarce and chances of missing and misplacing the records are very common. The very challenging issue is the transition process of paper based to electronics based medical records. Implementing of quality is the change process when it comes down to EMR which also considered a complex and difficult multidisciplinary effort that will stretch an organization's skills and capacity for quality management change process. After thorough analysis and research, there seems to be many challenges in implementation and transition itself such as
2 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 2 of 11 vendor selection and planning for EMR implementation, burdens of Existing paper based medical records, and conversions process of frantic Paper Base Medical Records to EMR. To tackle the above listed quality problems, quality management team at Holy Cross is preparing to replace the current Paper Based Medical records into EMR through proper analysis and research. It is no wonder that getting into the edge of health informatics means a value added design for quality thereby increasing competitiveness, in the other side-reduces human error, remove rework; save time, many lives and avoid millions of dollars. Research paper outlines many quality approaches of electronic medical records like reducing redundant care, speeding patient treatment, improving safety and keeping patients healthier, at the same time meeting and exceeding standards. 2. INTRODUCTION Holy Cross Hospital (HCH) in Fort Lauderdale, Florida, is a full-service, non-profit Catholic hospital, sponsored by the Sisters of Mercy and a member of Catholic Health East. Since hospital opened its doors in 1955, the name Holy Cross remains synonymous with medical excellence and highly personalized care with sincere human compassion and understanding. The department consists of outstanding and world class of services with combined services it provides following with the advancement with technology and informatics available. The Hospital s rapid growth has allowed advancing with the dramatic improvements achieved in healthcare through the means of technology. Holy Cross in Broward County, where it operates is one of the greatest concentrations of medical talent in the community; medical staff consists of more than 600 highly skilled physicians representing just about every specialty in medicine. This is the reason why patients are attracted from around South Florida, across the United States and around the globe. Since opening its doors, Holy Cross has grown to keep pace with the needs of the community it serves Patient capacity has increased from 100 patients in 1955 to the 571 patients we are licensed to serve today. Over the years there has been and will continue to be many exciting changes and opportunities for all of us who serve you at Holy Cross. Well into the future Holy Cross is dedicated to maximizing the opportunities that are presented to our medical professionals and staff by being innovative through the access of technology.
3 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 3 of 11 The physical appearance and size of Holy Cross may continue to change but the purpose and character of the institution remain constant: The establishment, maintenance and operation of a modern Catholic community medical center and scientific institution devoted to healing (Holy Cross Hospital). Holy cross with its commitment consists of many departments - Comprehensive Cancer Center, The Zachariah Family Wellness Pavilion, Jim Moran Heart and Vascular Center, Comprehensive Bariatric/Obesity services, Maternal/Child Health services, Epilepsy Monitoring Unit, Sleep Disorders Lab, Emergency and outpatient services, Intensive Rehabilitation. While HCH is playing an essential role in the way it cares to its patients, hospital also includes also maintain state-of-the-art technology, a highly acclaimed medical staff and a variety of innovative services to provide healthcare for the entire family. Holy Cross is accredited by the Joint Commission and is the first hospital in Broward County to be designated a Magnet Hospital by the American Nurses Credentialing Center. The mission of Holy Cross Hospital is to serve the healthcare needs of persons of all faiths and cultures by providing quality health care with Christ-like compassion. It upholds the ethical and moral teachings of the Catholic Church in all policies and practices. While keeping these promises, maintaining moral and meeting standards with changing technology is sometime hard to do. 3. MAJOR PROBLEMS, ISSUES AND OPPORTUNITIES Health information and medical records department is facing an enormous problems in maintaining medical records- as hospitals is growing and covering many communities in Florida and around the Globe. HCH facing challenges in keeping paper based records in file, loaded into the rooms and dig them when one needs them, in short or sometime after very long time. This is making difficult for the department to manage medical records and make available to patients and clinicians to access when required. The second issue is the burden that bounces doctors and makes them difficult to process records of the patients in timely fashion. The very challenging issue is the changing / transition process of change to EMR which is very hard to do. Quality Problems Vendor selection and Planning for EMR implementation Burdens of Existing paper based medical records and solutions.
4 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 4 of 11 Conversions of frantic Paper Base Medical Records to Electronic Medical Records Cost of Transition and Quality Holy Cross has already decided the EMR vendor/ IT department for process, planning and implementation by which quality will be assured and problems will be solved. There is much to decide upon while planning phase and one of the huge problems is management of existing, paper based medical records. According to the experts I talked, each practice that converts from a paper-based system to an EMR has to go through this process and make the decisions that HCH facing now. While researching vendor, I spoke with two of them and their response is very common. They suggested that old paper based medical records should be scan according to the need based preferences or with more trained professional. This will minimize the chance of missing or loss of important information while transforming into the electronic database through various methods while managing quality through change base approach. Opportunities seem to be many with successful implementation of EMR in the hospital. HCH outline many advantages on quality of services that could be offered to the patients through traditional approach of electronic medical records. Major benefits to the hospitals by implementation of electronic medical records is the idea that every time a doctor or nurse sees a patient, a whole database of information is instantly available, including allergies, underlying conditions and test results which will results in quality of care and quick services to patients/ customers in a timely manner. 4. ANALYSIS OF THE ORGANIZATIONS AND BUSINESS PROCESSES HCH realizes shortcoming can be overcome by quality transition process of paper based medical records to Electronic Medical Records while maintaining the latest technology in information and medical records. While transition is very crucial in meeting quality and standards, implementation is difficult then it was thought making quality process more complicated. The problems also relate here, doctors are unable to comprehend the patient's history and select suitable medical treatment. In paper based medical records, medical events from examination, treatment etc. are documented successively, and problem oriented recording is difficult to be applied to patients with much information and a long history. Consequently it is not easy to understand the patient's history from paper based medical records.
5 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 5 of ANALYSIS OF REQUIREMENTS FOR SOLUTION IN EMR IMPLEMENTATION. In order to solve this problem, HCH want to replace the old paper based model of patients records keeping and to develop the flow sheet system in electronic medical record (EMR). According to the quality assurance officer, to make a flow sheet, technology department analyzed the structure of the medical event data. Furthermore, HCH clarified the specification of the data presentation on the flow sheet then develop the flow sheet on the basis of these analyses. These results into many items of the medical event can be displayed on the screen. When user clicks the cell, the corresponding detail data including images are shown. This system functions to link medical event items with a problem, and shows the bundled items on the flow sheet when the user selects the problem (Chin H.L. pp ). After research, I found that the implementation means managing quality while meeting or exceeding challenges but not easy to achieve. The medical doctors in HCH evaluated this system, and conclude that the flow sheet data presentation makes comprehension of the patient's history easier than paper based records which was already been proved by many experts in the field. From understanding the process of EMR functions of bundling the items relevant to the problem, HCH feel it is especially useful for patients with chronic disease. Thus the flow sheet data presentation in EMR is useful for medical practice giving many advantages over paper based medical records while solving the quality problems and meeting expectations. High Cost of Quality : Issues triggers right here about budgeting which needs to be passed and agreed from the high-level budgeting and direction were set by the leaders of the HCH, the project team was empowered, within broad boundaries, to make decisions--enabling quick resolution of issues that arose during system deployment. Many of the project team members were end users of the system, providing a close link between decisions made and the impact of those decisions. HCH realizes it close coordination and cooperation of operations, Holy Cross medical Group, and Information Technology in joint quality management and decision making was an important factor in making the transition successful. For solution of better implementation, it struggles in which quality management has to be more active including the role and course of operations for project management expertise. Holy Cross Medical Group for the clinical
6 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 6 of 11 expertise and Information Technology for technical expertise remain important power in making the transition fruitful which will in turn binds all the expertise into one single character of multiqualities (Peterson, N.L., p. 9-11). As information systems project of transition progresses, HCH also recognize solutions for additional functional requirements to sidle into the project. After analysis it has been understood that, most additional requirements that are added in this way appear begin at first but have significant hidden downstream impacts. Considering this project of transition is complex, team at HCH fulfill the necessary steps of evaluation which could introduce a shortage of clarity that may result in significant delays and rework. This will also help HCH to avoid some scope creep and to understand that any change in scope may reduce the prospect of accomplishment of the overall transition process. A result from research also prioritizes on special people who are able to bridge the gap and the cultural divide between the end user, the organization, medical staffs and IT people. IT people are accordingly able to think analytically and can comprehend and translate between end users, the project team, and the organization which may results the quality management more successful in meeting the challenges ( Jick, T.D., p. 81). Power of EMR, the opportunity exists to use an order requisition as a way to communicate not only from the clinician to the ancillary department but also as a way for the hospital to correspond to the clinician at the time of ordering. According to my understanding from the book and knowledge from discussion over several weeks, inserting guiding information in an order requisition, direction can be delivered to the clinician seamlessly during the ordering process. Here we can include an the example of a simple but operative way to embed useful content is to automatically print patient information related to an order on the after-visit summary that is given to the patient at the end of the visit (Ash J.H., p. 71). 6. PROPER QUALITY IMPLEMENTATION PROCESS CHALLENGING TRANSITION For proper implementation process, no one knows about the perfection but one should think about the flip side rescuing from rolling it out further until the system is at least "good enough" in the locations that you have already implemented. While paper based transition to EMR looks very complicated, it remains very important to recognized significant problems or
7 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 7 of 11 issues, fix them and delay further roll out until those issues or problems are sufficiently addressed. Holy Cross also gave the training to task when a clinician has undergone initial training for EMR. More evidently, many clinicians know enough to get by, but proved to most quickly forget much of what they learned in the primary system training. According to the Holy Cross, in an evaluation of clinicians, the found that more of its clinicians remembered less than 60% of what we felt essential material taught to them in the initial system deployment. In addition, information systems and capabilities are constantly changing. HCH found it s a hard way to implement the EMR because of ongoing and continued evaluation, education, and training are necessary to optimize clinician effectiveness and success (Holy Cross Web site). Many quality system implementers believe that once a system is implemented, their work is done. The truth of the matter is that these systems are constantly changing. Application software, operating systems, hardware, technology, and medical knowledge about diagnosis and treatment are constantly changing and having that within the system is very competitive in meeting quality expectation (Ash J.H p.69-70). According to HL Chin, the EMR is the great magnifier. If an organization already does something very well, addition of EMR type technology- the implementation of information technology will probably further improve its performance means increase quality in services. However, if an organization is dysfunctional in an area, then the implementation of an EMR will probably magnify that dysfunction. Identifying and addressing potential areas of organizational dysfunction prior to implementing the EMR may improve the overall results of quality management and implementation. (Chin H.L., pp.771) 7. GAINING COMPETITIVE ADVANTAGE BY MANAGING QUALITY After research and understanding I found that Holy Cross is weak in three major critical aspects in quality management where by patient s records and successful transition of those paper base models to Electronic Model database. From analysis results, HCH could only achieve the goal of proper implementation with proper human capital, HCH capabilities, and core competencies. It was assumed that HCH capabilities and core competencies require the right kind of technical savvy in order to be created and sustained by corporations. It also found to
8 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 8 of 11 require the right administrative systems and quality management styles, but they clearly rest on the talent of the individuals in the company (Peterson, N.L., p ) In order to for HCH to be successful in transition of paper base to electronic medical records, company also realized on its capabilities that allow them to coordinate and focus on the change process and technical requirements on employees, and healthcare professional. For proper implementation, it was also assumed that effective quality management was necessary for EMR transition which would also help in producing high levels of performance in professionals during the implementation process. In some respects, EMR implementation in one side is the ability to change rapidly and other benefits is the ultimate competitive advantage. It is the ultimate competitive advantage because it potentially enables the hospital to stay ahead of its competitors and meet the increasingly higher performance standards that the healthcare informatics with quality of services it could offer (Schauer, J. (1998). In addition, HCH must achieve the quality goal only with improvement in informatics in healthcare environment that is rapidly changing. To avoid losing out in this new competitive world that asks companies simultaneously to improve quality, lower costs, bring new technological inventions to patients to provide quality care through innovation, which will also improve HCH performance. This will also fulfill three of the main problem of managing overload of papers records, meeting quality standards in caring patients and helping clinicians to be more effective in preparing and accessing records promptly. 8. ANALYSIS OF QUALITY IMPLEMENTING PROCESS AND ITS CONSEQUENCES After all the research, I found that quality management is the process where superior services and products are made available but with some or many consequences like higher cost associated in increasing quality, managing the process, upgrading the systems and change of the business process. In relation with this project paper, the traditional paper based system, found to be discrete and must be re-evaluated with quality assurance. A new, realistic, technologicalcreation model for the information systems must be constructed in based need standards with quality management which would then have consequences of increased quality cost or will face low quality and business failure. Investment must be increased on IT infrastructures to include EMR, and new EMR training projects with both scale and appropriate timing needed to be captured while quality implementation process.
9 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 9 of CONCLUSION After researching and analyzing quality based approach of both paper based and EMR system, I found that quality implementation a very complex and difficult multidisciplinary effort that will stretch skills, capacity and resources but upon successful implementation, benefits are long lasting impression for any company in meeting customers expectations through higher quality of products and services. Although quality management process looks very challenging and daunting, the logical benefits while researching and preparing this project paper about Electronics Medical Records is a good experience to learn that achieving quality outpace other consequences like cost for quality, resources and difficult task of managing it. This effort will increase productivity, the cost of operations, and the quality of the services by proper implementation process will create customer satisfaction, of which all contribute to profitability. Six Sigma Approach to Address the Quality Management Problems I consider using Six Sigma approach to identify and resolve the problems associated with quality management of medical records. Therefore, I recommend the management team to create measurement systems before collecting data s. Furthermore, I also informed quality management team to apply Six Sigma to which would then require examination of four key measures of the performance to effectively maintain quality. i. Accuracy on correct financial figures, completeness of information ii. Cycle time, time to finish the quality process or task to complete which may increase quality iii. Cost, that is, the internal cost of quality process iv. Customer satisfaction, the primary measure of success From my understanding, I would recommend the principal problem solving methodology used by Six Sigma- DMAIC-define, measure, analyze, improve, and control. Step 1 is to Define: The first step is to clearly define the problem. This activity is significantly different from project selection. Project selection generally responds to symptoms of a problem and in this project would be time consuming paper based records. Step 2 is to Measure: This is the process focuses on how to measure the internal processes that impact CTQs. It requires an understanding of the causal relationships between process performance and customer value.
10 The International Journal of STEM-Journal of Health Information Systems-, 2012, Vol. 224 Page 10 of 11 Step 3 is to Analyze: A major flaw in many problem-solving approaches is a lack of emphasis on rigorous analysis. The Analyze phase of DMAIC focuses on why defects, errors, or excessive variation occur. Step 4 is to improve: in this context by following the standards of Six Sigma, HCH would be able to improve its quality of products and services by improving its paper based records systems to electronics medical records. Step 4 is to control: Control phase would focuses on how to maintain the improvements of services in providing the quick services, which would include positioning tools in place to ensure quick access of patients records by clinicians and doctors resulting into the time saving for customer and in other hand records will be more secure in electronic under the modified process (Managing quality p.562) REFERENCES Ash, J.S., Stavri, P.Z., Dykstra, R., Fournier L. Implementing computerized physician order entry: the importance of special people. Int. J Med Info 2003 Mar; 69(2-3): Ball, M. J., & Weaver, C. A., (2004). In Kiel, J. M., Healthcare Information Management Systems (3rd ed.). Springer pp. 63, 68, 81-85, 101, Chin HL, McClure P. Evaluating a comprehensive outpatient clinical information system: a case study and model for system evaluation. Proc Annu Symp Comput Appl Med Care 1995: EMR Cost and Benefits, Tuning Good Practices into Good Management. Reviewed, April 07, 2011 from, Evans, J.R. and Lindsey, W.M (2011), Managing for Quality and Performance Excellence, 8th Edition, South Western Educational Publishing (p , , 588, 591) Gides, G. (2011). The EMR installation disconnect. Health Management Technology, 32(2), 36. Retrieved from Holland, D., & Skarke, G. (2003, July/August). Change management for big systems. Industrial Management, 45(4), Jick, T. D., (1995, Summer). Accelerating change for competitive advantage. Organizational Dynamics, 24(1),
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