& Your HIS. Electronic Health Record System. The Dynamic Duo. Everything you need to know to create a Paperless and Process efficient Hospital.

Transcription

1 Electronic Health Record System & Your HIS The Dynamic Duo Everything you need to know to create a Paperless and Process efficient Hospital.

2 Table of Contents Introduction 2 What is EHR? 2 What is HIS? 4 What is the difference: EHR & EMR? 5 Two Systems One Tool 8 Who we are & What we do 10 1

3 Introduction EHR (Electronic Health Records Systems) and HIS (Hospital Information Systems) are Complementary Tools that can reach their full Potential in a Hospital when paired together. Not only can these tools improve Operational efficiency & plug revenue loss but also help the hospital go Paperless across Departments & protect themselves from Medico Legal Cases. Patient Centric Cross Department Workflows that can be achieved by integrating the two tools, can be an easy, smooth and pleasant experience for your Patients at your Facility. If you re thinking about integrating your existing HIS with an EHR system or planning to procure a new HIS system, it s important that you understand the benefits this will provide, and make the right choice of the product, and ensure that you don t have to reinvest or change your system later. So, let s get started The Idea 01 What is EHR? Chapter in Brief Electronic Health Records is becoming essential as the Patients demand the same, and the Government has regulated standards for EHR & HIT Key Takeaways Effective use of EHR Systems can improve cross department operational efficiency, Improve revenue, reduce clinical errors and Medico Legal Cases, and get your organization go paper less. The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. The EHR automates and streamlines the clinician s workflow and has the ability to generate a complete record of a clinical patient encounter -as well as supporting other care-related activities directly or indirectly via interface -including evidencebased decision support, quality management and outcomes reporting. 2

4 When an EHR system is paired with a HIS, data can be seamlessly passed between the two, allowing users (both Clinicians and nonclinicians) to track and analyse all touch points a patient undergoes at the facility and it can also significantly improve efficiency by automating the cross departmental workflows traditionally performed manually. It is important to note that an EHR is generated and maintained within an institution, such as a hospital, clinic, or Doctor s office, to give patients, Doctors and other healthcare providers, employers, and payers or insurers access to a patient s medical records across facilities. A basic EHR system typically offers: Creation, access and maintenance of Patient Electronic Health Records compliant to Standards. Interoperability of Patient s Electronic Health Records Accelerated healthcare delivery Simplifies the coordination of care Automates end-to-end Management of care Reduces Clinical Errors Reduces Costs Eliminates constraints of place (Any time Any Where) And the numerous advantages of Electronic Vs Paper The Government of India, under the Ministry of Health and family welfare released a Standards for Healthcare Information Technology (HIT) and EHR Compliance, in August 2013, and has been driving healthcare facilities to comply with the EHR standards. They ensure the Standards are mandatory for all Government initiatives and it s expected the private players will be mandated to comply in the next 2 years. Download our HIT & EHR Compliance Check List Download GOI Standards Specification for HIT & EHR 3

5 What is HIS? Chapter in Brief Idea Indian Govt. has prescribed standards on HIT & EHR for HIS vendors to comply. 02The Ensure your HIS is compliant to these standards. Key Takeaways While an HIS is a minimalistic approach that hospitals could take to run operations in the past, with Customers awareness, Government regulation and raising medico legal cases, Hospitals need to protect themselves with an EHR system A Hospital Information System (HIS) is an element of Healthcare Information Technology (HIT) that focuses mainly on the administrational needs of hospitals. In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the aspects of a hospital s operation, such as medical, administrative, financial, and legal activities and the corresponding processing of these services. However Majority of Indian HIS systems do not handle the medical or clinical processes of the hospital operations and a few may have very minimalistic EMR s, which do not comply with the HIT & EHR standards regulated by the Govt. of India. A basic HIS system typically offers: Appointments, Scheduling, Patient Registration Admission, Discharges and Transfer 4 Doctor Pay-outs Billing, Contract Management, Package Deal Designer and Accounts Receivables Consumption Entry Laboratory, Radiology and Cardiology Reporting Discharge summary Material Management System - Pharmacy, Main Stores and Purchase Management Reporting 3rd Party financial System Interface In India most HISs are Billing centric, yet billing is handled manually, with each line item in the bill being entered by hand, and there is no way to automate and ensure that all clinical services provided have been billed to plug the gap of revenue loss through non billing of services that have been rendered. As these HISs only handle the financial and administration side of the facility, the patient s experience at the facility, at most times is unsatisfactory, as the system cannot be set up with patient centric cross departmental workflows. This leads to patients waiting at most financial touch points at the facility (like waiting for a bill to be prepared) for information to arrive manually and then fed into the system. Additionally, these HISs do not give the facility any cover against Medico Legal Cases that are growing in the country, due to the lack of recording any clinical information in these systems, as required.

6 Chapter in Brief Idea Electronic Health Records (EHR), and Electronic Medical Records (EMR) are not the same, in spite 03The of a lot of People using the words Interchangeably. What is the difference: EHR & EMR? What s in a word? Or, even one letter of an acronym? Key Takeaways EMR need not comply with standards, and cannot provide interoperable health records or provide Clinical decision support or any of the various benefits of an EHR System. Some people use the terms Electronic Medical Record and Electronic Health Record (or EMR and EHR ) interchangeably. But the Office of the National Coordinator for Health Information Technology (ONC) in the USA, use Electronic Health Record or EHR almost exclusively. While it may seem a little picky at first, the difference between the two terms is actually quite significant. The EMR term came along first, and indeed, early EMRs were medical. They were for use by clinicians mostly for diagnosis and treatment. In contrast, health relates to The condition of being sound in body, mind and spirit; especially freedom from physical disease or pain the general condition of the body. The word health covers a lot more territory than the word medical, and EHRs go a lot further than EMRs. What s the Difference? Electronic Medical Records (EMRs) are a digital version of the paper charts in the clinician s office. An EMR contains the medical and treatment history of the patients in one s practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to: Track data over time Easily identify which patients are due for preventive screenings or check-ups Check how their patients are doing on certain parameters such as blood pressure readings or vaccinations Monitor and improve overall quality of care within the practice But the information in EMRs doesn t travel easily out of the practice. In fact, the patient s record might even have to be printed out and delivered by mail when referring to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record. Electronic health records (EHRs) do all those things and more. EHRs focus on the total health of the patient going beyond standard clinical data collected in the provider s office and inclusive of a broader view about a patient s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the 5

7 information. They are built to share information with other healthcare providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient s care. The National Alliance for Health Information Technology in the USA stated that EHR data can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. The information moves with the patient to the specialist, the hospital, the nursing home, the next state or even across the country. In comparing the differences between record types, HIMSS Analytics Stated that, The EHR represents the ability to easily share medical information among stakeholders and to have a patient s information follow him or her through the various modalities of care engaged by that individual. EHRs are designed to be accessed by all people involved in the patients care including the patients themselves. Indeed, that is an explicit expectation in the Stage 1 definition of meaningful use of EHRs. This makes all the difference. Because when information is shared in a secure way, it becomes more powerful. Healthcare is a team effort, and shared information supports that effort. After all, much of the value derived from the healthcare delivery system results from the effective communication of information from one party to another and, ultimately, the ability of multiple parties to engage in interactive communication of information. Benefits of EHRs With fully functional EHRs, all members of the team have ready access to the latest information allowing for more coordinated, patient-centred care. With EHRs: The information gathered by the primary care provider tells the emergency department clinician about the patient s life threatening allergy, so that care can be adjusted appropriately, even if the patient is unconscious. A patient can log on to his own record and see the trend of his lab results over the last year, which can motivate him to take his medications and carry out lifestyle changes that improves his health. The lab results run last week are already in the record to tell the specialist what she needs to know without running duplicate tests. The clinician s notes from the patient s hospital stay can help inform the discharge instructions and follow-up care and enable the patient to move from one care setting to another more smoothly. So, yes, the difference between Electronic Medical Records and Electronic Health Records is just one word. But in that word there is a world of difference. Further in India the EMR systems are quite primitive that they just use a few text boxes to capture a little clinical data, and do not comply with any specific standards. 6

8 Chapter in Brief Idea An Integrated HIS & EHR can be Smarter. Further EHR Systems have also evolved and today can do much more to help improve 04The Quality of Care delivery at healthcare facilities Key Takeaways An Integrated HIS & EHR can improve efficiency, Customer satisfaction, Increase revenue, Reduce Clinical errors and plug revenue leaks on unbilled services. Two Systems One Tool EHR systems have evolved to be smarter than before in the last few years, providing tangible benefits and addressing real pain points healthcare providers face. Integrated HIS with EHR, no service ever goes unbilled The disconnect between HIS (Hospital information Systems) and EHR systems is no longer acceptable, as billing should no longer be handled manually. In most cases the bill line items are based on a clinical action, like administering a medication or IV fluid An HIS with an integrated EHR can automatically trigger the bill line item as the associated clinical action takes place, thus avoiding the risk of not including a service into the bill. Patient centric Workflows, that brings in Finance, Operations, Clinical & Inventory processes all in to smooth workflows & a good patient experience. Systems built with patient centric workflows improves efficiency and the patient experience at the healthcare facility. Such Workflows would involve multiple patient touch points with various processes like Billing, Doctors, Pharmacy, Lab, Nursing both from the Clinical and nonclinical teams in the facility. An HIS integrated with EHR can ensure that all patients care workflows, involving both Clinician and Non Clinical teams, can be automated. 7

9 Patient Lifecycle Management, ensures you retain them through their longitudinal care requirement. Patient Lifecycle Management helps retain patients who need longitudinal care for Chronic conditions like Diabetes, Hypertension etc. or even Pregnancy or Pediatrics. Setting up Lifecycles for various conditions and then creating milestones and activities (clinical activities/ hospital visits) that need to be achieved during each milestone. Tracking the patient through the lifecycle with automated reminders, context based education and patient communication can help ensure patients are retained by the Healthcare provider by brand building and loyalty to the healthcare facility. An HIS integrated with EHR is essential to build an effective and automated patient Lifecycle Management System. CDSS to reduce/avoid Clinical Errors & Medico Legal Cases Smart EHR Systems come with a strong Clinical Decision Support System (CDSS) Engine. CDSS engines will need to have a Drug Information framework and Knowledge base, that alerts clinicians of Contraindications on Drug to Drug, Drug to Disease, Drug to Allergies, Pregnancy, Lactating etc. and furthermore Hepatic and Renal insufficiency dose adjustments. Also will alert and do the required adjustments for Pediatric and Weight/BSI based dosage and intelligence for generic or therapeutic substitutes of medication. While CDSS can reduce clinical errors, EHR clinical documentation protects them from Medico legal cases. e-prescriptions to avoid errors & improve efficiency at your Pharmacy Counter /stores, Lab, Radiology & Nursing stations. CPOE Computerised Provider Order Entry which is part of the EHR, provides the Doctor s Orders for Pharmacy, Lab, Radiology & Nursing to be sent electronically for further billing / sample collection / administration or processing. Since e-prescriptions avoid the need to retype the Doctor s orders, it improves efficiency and avoids errors. At a Pharmacy the bill can be generated from the e-prescription without having to type in the orders. Clinical Care Pathways, to ensure quality of healthcare delivery Core clinical teams in healthcare facilities can create Clinical Care pathways by defining Clinical Protocols or cross discipline Order sets in the EHR to be followed for specific Clinical Conditions, which makes 8

10 it easy for the rest of the clinicians to follow. This ensures junior clinicians do not miss out necessary clinical actions thus resulting in best practice healthcare delivery at the facility. The Core team can review the Clinical Protocols followed and update them from time to time. Patient Portal, with access to Context based Patient education Content Patient Portal helps in brand building for the healthcare facility. Apart from allowing the patients access to their healthcare records and view context based patient education content, it also allows patients to pre-register and keep their demography details updated. It can improve efficiency by allowing the patients to book/cancel/reschedule appointments themselves. The EHR enabled patient portal also allows them to export their Standards Compliant / interoperable Electronic Health Record. It s important for Healthcare facilities to build brand and the loyalty of their consumers and not just bank on the clinicians to bring in the patients to the facility. Interoperable & standards compliant Patient Health Records An EHR that complies with Standards for Interoperable health records enables patients share their healthcare records across facilities during their longitudinal care. This saves them cost of repetition of diagnostic tests. Further it avoids the need and practise of carrying around physical files every time they meet clinicians, irrespective of who (patient/facility) maintains 9 the physical file. The EHR also allows Clinicians to access and research their patient records from anywhere, well in advance before meeting them. Dashboards for Financial, Operational & Clinical Efficiency Smart EHR systems that are integrated with HIS systems can not only provide Dashboards on finical & operational efficiency of the facility, but also clinical efficiency and insights into clinical data. High Functionality & High Usability ensures adoption by clinicians. Unlike other IT systems where Functionality viz-a-viz Usability of a product is always inversely proportional, to get Clinicians to adopt to using EHR systems, it s extremely important for the system to be high on Functionality and Usability. Doctors will not adopt to EHR partially, they either fully adopt or they just do not adopt, and the common reasons they do not adopt is if the system lacks some Functionality or Usability. A good EHR ensures that there is minimal or zero typing that the Doctor has to do to use the system, and manage everything with mouse clicks or touch screen. The system has artificial intelligence built in to learn the Doctors usage and adapts itself to suit the Doctor usage. While the Doctor goes thru the system just with mouse clicks or touch screen, the system should be able to generate elaborate documentation of the consult/ discharge summary etc. automatically. The Doctors expectation is that they should be able to consult faster on an EHR system and see more patients, than if they used pen and paper.

11 Who we are What we do We are an organization of Healthcare IT Domain Experts with a collective experience of more than 100 man years in the areas of Hospital Software Development with expertise in Cloud Engineering, Analytics and Big Data,Mobility solutions. We operate with dedicated focus on EHR Technology Framework with experience in developing and deploying products in highly competitive International Markets and we strive to support our customers with best practices in Healthcare Management through our domain expertise and End-to-End mature Hospital Software Solutions. The world is in the threshold of an impending paradigm shift in the way healthcare is delivered and individual health records managed. With the accelerating adoption of EHR standards, we, at Lifetrenz, are positioned appropriately to ride ahead and become torchbearers of IT enabling this revolution. We builds innovative IT Solutions to power global healthcare providers. Our products are built on modern technology, comply with International EHR (Electronic Health Records) standards and are intuitive to use. Our Solutions combine the power of Cloud with the rich user experience of a desktop application in its Smart Client Web Application delivered as a service from a cloud infrastructure or onsite. We are an innovative company finding success and satisfaction in being able to work closely with our clients in areas that are critical to their success. Our solutions focus patient and customer satisfaction. We are nimble footed when it comes to speed of implementation and we take great pride in being a thinking organization. We see each engagement as an opportunity to collaborate with our clients and ensure maximum return on their investment. We build IT solutions that enable healthcare providers deliver safer healthcare, economically, so as to make quality healthcare more affordable for people across all socio-economic strata. The service delivered as pay-per-use SAAS (Software As A Service) from our public cloud enables healthcare providers of all sizes and segments to consume these services as they need. Our service sits on top of an extensive and evolving knowledge base of information and tools that enable the users of the service to improve the safety, quality and speed of their work. Any professional person or organization in Healthcare wishing to streamline their practice and align their work to International standards and best practices will find that Lifetrenz makes this a smooth journey. Though there are many local and regional players in this segment, it is largely fragmented and looked at more from an operations perspective and not so much from clinical information side. Lifetrenz turns the table around to look at the whole solution from a patient centric perspective with the capture and storage of patient clinical data using EHR standards. The EHR Technology Framework of Lifetrenz is built on Open Source Technologies incorporating features like scalability, all round security and minimal set-up and go-live requirements, blending best of functionality with user-friendliness. The EHR Product is completely engineered in house by Lifetrenz, taking into account the Domain Expertise to provide an up-to-date Technology to Hospital software customers. All our Hospital Management Software products like Lifetrenz Hospital, Lifetrenz EHR and Lifetrenz Polyclinic are engineered to be interoperable, based on International and Indian EHR Standards. The products are highly reliable, scalable and patient-centric for Healthcare Workflows across product verticals/providers for a comprehensive, holistic Healthcare ecosystem founded on knowledge framework with features to provide modular up gradation and enable Continuity of Care. 10

12 Electronic Health Record System & Your HIS The Dynamic Duo