User Manual. MDAnalyze A Reference Guide

Transcription

1 User Manual MDAnalyze A Reference Guide

2 Document Status The controlled master of this document is available on-line. Hard copies of this document are for information only and are not subject to document control. Document Version Number and Date are used to identify this deliverable for the purpose of configuration control. Document Name.doc Status Final Document Version Number 1.0 Date 28/11/2011 Amendment History Change Request Number (optional) Document Version Number Date Modified By Section, Page(s) and Text Revised /11/2011 Karen Post Initial Creation Document Control The functional area of the Asset Library to which this document belongs is recorded in this section. Process Owner Karen Post, Dept of Surgery Business Analyst Page 2 of 34

3 Table of Contents Chapter 1 Introduction... 4 Where is MDAnalyze Installed?... 4 Who enters the Information?... 4 How is it used in Orthopaedics?... 4 Chapter 2 Concepts... 6 Master Patient Index... 6 Sharing Data between Specialties... 6 Navigation... 6 Chapter 3 Main Functions... 8 Admissions... 8 Recording Complications Recording Diagnoses Discharges Clinic Visits Recording Operations Past Histories Add an Operation Suggested Workflow Chapter 4 Tips Saving and Changing Data Activating a List Order of Entry Related Diagnosis Billing Codes Templates Known Bugs Chapter 5 Other Features Custom Forms Search and Analysis Function Log Book Media Centre Reporting Page 3 of 34

4 Introduction Chapter 1 Introduction MDAnalyze is a solution purchased by the Royal Children s Hospital (RCH) Department Of Surgery to support the surgical audit requirements of the Department. It has been used in the RCH Orthopaedic Department since 2004 and was enhanced in June 2011 to enable it to be used by all surgical units. Where is MDAnalyze Installed? MDAnalyze is installed in the following locations: Surgical specialty administration and clinic rooms Day Surgery and Main Theatre write-up areas Orthotics Department Health Information Services Physiotherapy Department Who enters the Information? Demographic, admission and clinic visit information is automatically added and updated from IBA the patient information system used by the RCH. For example, each time a patient is registered on IBA, attends an outpatient appointment, or is admitted, a subset of the information entered in IBA is sent to MDAnalyze. MDAnalyze also receives changes to IBA patient demographic data such as patient merges, name and address updates and changes to admissions such as cancellations etc. Each department can determine how best to utilise the functionality in MDAnalyze but as a minimum, operation and complication data must be entered. How is it used in Orthopaedics? In Orthopaedics it is the registrars and fellows responsibility to: Enter diagnoses Enter and print Operation Reports Enter admission notes for non-surgical admissions Enter complications of a nature that would be discussed at the Orthopaedic Departments M & M meetings Every Wednesday morning the department runs a meeting and reviews the previous weeks admissions and operations. The MDAnalyze Admissions and Operations Report forms the basis of the review and this is printed and distributed by a registrar. Page 4 of 34

5 Introduction The Complications Report forms the basis of Orthopaedic Department M & M meetings. It is the registrars responsibility to prepare for the M & M meeting and this includes printing the Complications Report. The clinic visit functionality in MDAnalyze is utilised by the Orthopaedic Clinical Nurse Specialists and the Orthopaedic Physiotherapists. For example the clinic visit notes are entered in MDAnalyze and then printed on the standard RCH Outpatient form and then scanned as part of the ESMR. Each department needs to determine how best to utilise the functionality in MDAnalyze. As a result, they may decide to follow the same working practices as Orthopaedics or implement their own. Page 5 of 34

6 Concepts Chapter 2 Concepts Master Patient Index MDAnalyze has one database for each specialty and the Master Patient Index (MPI) database. The MPI is a link between IBA and the specialty databases. It is used to transfer information from IBA to the specialty databases and between the specialty databases. As a result, the MPI contains a summary of all the information in the specialty databases and is used for management reporting. For example a report can be run from the MPI showing all complications for all specialties. All users have access to the MPI to view information, but the ability to run reports from the MPI is a secured function. Sharing Data between Specialties Each surgical specialty has its own database but data is shared between the specialties. For example, within your specialty you will see all the admissions, clinic visits and operations for that patient regardless of the admitting unit, type of outpatient appointment or the specialty that added the operation. Not all the data is shared between the specialities. For example you will not see the operation codes and billing codes for an operation added via another specialty and you will not see the anatomies, pathologies and presentations for a diagnosis added for another specialty. Some of the complication data is also not shared, such as type, class, peer practice, documented flag and comments. Navigation Access to MDAnalyze functions is managed via a tool bar and a set of icons. Use the menus and icons to access the following MDAnalyze functions. Open the Media Centre. Run the Admission and Operation and Complication Report. Add and view investigations. Administrative tools (secured function). Add a patient (secured function). Find a patient. Open the Search and Analysis Function. Page 6 of 34

7 Concepts Control preferences. user Patient reports. level Online Help. Exit MDAnalyze. Hide/display the toolbar and status bar. Search. add, delete and undelete a patient (secured function). If you have access to more than one database you can swap between databases using the list box shown in the screen shot below. This allows you to jump between databases. Page 7 of 34

8 Main Functions Chapter 3 Main Functions Admissions When a patient is admitted to IBA, the admission is automatically added to MDAnalyze. All patients admitted to the RCH are added to MDAnalyze, this includes admissions to non-surgical departments. For example if you have logged on the paediatric and Neonates database and the patient you are viewing has been admitted to Neonates and Plastics, you will see both admissions as shown in the example below. The following admission information is added from IBA: Admission Date (admitting date in IBA) Admission Source (admitting unit in IBA) Hospital (always RCH) Doctor (admitting surgeon in IBA) An example of the admission screen Page 8 of 34

9 Main Functions To associate a diagnosis with an admission, click on the white space below the Diagnosis Description field (1). A list box will be displayed showing all the diagnoses for that patient. You can add multiple diagnoses for an admission. To enter a complication for an admission, press the tree icon next to Select Complication And Sequala (2). This will display a list of all the complication codes. Select the relevant code and then enter the rest of the complication details. To select a score, click on the Assessment and Scores tab (3). MDAnalyze allows you to select a score at admission and then at discharge for comparison purposes. To select a score click on the magnifying glass. Select the relevant score and if a custom form is associated with that score, it will be displayed. You can also associate a diagnosis with a score. To record a procedure for an admission, click on the Procedures tab (4). Each specialty has a customised list of procedures. You can also associate a doctor and a billing code with a procedure. The Care Notes and Discharge Notes tabs (5) allow you to enter a textual description of the care given during the admission and instructions for discharge. Note that CLARA is still used to produce the Discharge Summary. Page 9 of 34

10 Main Functions Recording Complications The Department of Surgery has implemented a standard set of complication codes for all specialties. Complications are recorded against the admission they occurred in. In the example below, two complications with different dates have been recorded against the 18/02/2005 admission because the complications both resulted from an operation that occurred within that admitting period. As well as recording the complication against the admission, you record a diagnosis. In this case, a diagnosis of pin site infection was added and recorded against the admission on the 23/03/2005 which was the date the patient was admitted for the complication. Page 10 of 34

11 Main Functions Recording Diagnoses The Diagnosis screen allows you to enter a diagnosis for a patient. Each time a patient is admitted you associate a diagnosis with an admission. For example, if a patient is admitted in January for a fracture of the femur and in March for a fracture of the radius and ulna, that patient would have 2 diagnoses. In the next screen shot you can see that this patient has multiple diagnoses The diagnosis codes (1) in MDAnalyze are the ICD10 AM edition codes which are the same codes used by the RCH. The diagnosis description (2) allows you to further describe the diagnosis using free text. You can also select the anatomy, pathology and presentation (3) if it adds meaning to the diagnosis. If the diagnosis is bilateral, then a diagnosis is added for each side. This enhances the information on the Operation Report as it allows you to associate a procedure with a diagnosis, hence indicating which side the procedure applies to. If the diagnosis date is known, then this should be added. Page 11 of 34

12 Main Functions If a patient has multiple admissions for the same diagnosis for example Botox injections for cerebral palsy patients, a new diagnosis is not added for each admission. For these patients the diagnoses would be: Below is an example of the diagnoses for a patient with bilateral hip dysplasia. Page 12 of 34

13 Main Functions Discharges Discharge Summaries are still printed from CLARA and this is not expected to change. When a patient is discharged from IBA, the discharge date and destination from IBA will be automatically inserted in MDAnalyze. If an admission is cancelled in IBA, then the admission will still exist in MDAnalyze, but the discharge date will be set to the same date as the admission date and the discharge destination will be set to Cancelled. Page 13 of 34

14 Main Functions Clinic Visits Clinic visits are automatically loaded into MDAnalyze when an outpatient visit in IBA is marked as attended. The following IBA outpatient details are sent to MDAnalyze: Visit Date (appointment date in IBA) Current Location (clinic type in IBA) Review Method (always Seen in clinic ) An example of the clinic visit screen The Follow Ups function (1) can be used to as a reminder that a follow-up visit is required. Tick the Follow ups checkbox to enter a follow up. You can then create a query via the Search and Analysis function that you can run periodically to list the patients that have follow ups. The Disabilities function (2) is not currently used by the RCH. To select a score, click on the magnifying glass (3) under the Score Type. Select the relevant score and if a custom form is associated with that score, it will be displayed. You can also associate a diagnosis with a score. To record a procedure for an admission, click the tree icon (4). You can also associate a doctor and a billing code with a procedure. Once you have selected a procedure, click the tree icon (5) to add a billing code. Page 14 of 34

15 Main Functions Recording Operations Each department will determine what common set of information they will enter for an operation. An example of the Operation screen. 1 3 To add an operation to MDAnalyze, press the New Operation button (1). press New Operation, enter the following information: When you Surgeon: Name of the principle surgeon Description: Short description of the operation Hospital: Will default to RCH Date: Date the operation took place Op Priority: Indicates the priority of the operation Pre-Op Condition: Describes the state of the operation site pre-op Click on the Surgeons tab and build up a list of the surgeons associated with the operation. Enter the capacity and status for each surgeon. Click on the Operation Codes tab and enter the operation codes and billing codes ensuring you also select the appropriate related diagnosis for each operation code. Use the tree icons to select the operation and billing codes. Page 15 of 34

16 Main Functions Click on the Operation Diagnosis tab and select the diagnoses that are relevant to this operation. These are the diagnoses that will print on the Operation Report. Click on the Operation Notes tab and enter the operation notes. Remember you can select a template for the operation notes if required. To select a template press the icon (2) on the top of the Operation Notes tab 2 To print the Operation Report, press the Print Operation button (3) shown in the first screen shot then the printer icon and select the appropriate printer and tray. The Operation Report must print on the pre-printed RCH Operation Report form. Page 16 of 34

17 Main Functions Past Histories This function is not currently used. All diagnoses considered a co-morbidity, such as cerebral palsy and diabetes for example should be added as a diagnosis via the Diagnosis screen. Page 17 of 34

18 Main Functions Add an Operation Suggested Workflow The steps described below are the suggested steps to follow when adding an operation. 1. Add a Diagnosis. Go to the Diagnoses screen and enter the appropriate diagnosis if it doesn t already exist. 2. Associate a Diagnosis with an Admission. Go to the Admissions screen and associate a diagnosis with the admission by clicking on the white space below the diagnosis description. This will display the arrow and you can then select from the list of diagnoses. 3. Add an Operation. Add an operation by pressing the New Operation button. Ensure you enter the name, capacity and status for each surgeon involved in the operation. Enter the operation codes and billing codes and select the appropriate diagnosis for each operation code. Click on the Operation Diagnosis tab and select the diagnoses that are relevant to this operation. These are the diagnoses that will print on the Operation Report. Click on the Operation Notes tab and enter the operation notes. Remember you can select a template for the operation notes if required. 4. Print Operation Report. The Operation Report must be printed immediately after the operation. The last two pages of the Operation Report contain the Post- Surgical Orders. The Post-Surgical Orders must be completed and along with the Operation Report, handed to the nurses in post-op. To print the Operation Report, press the Print Operation button on the Operation screen. Page 18 of 34

19 Tips Chapter 4 Tips Saving and Changing Data MDAnalyze allows you to add, change or delete data at any point in time. For example if you have entered a diagnosis incorrectly you do not need to delete the diagnosis and start again, just change the incorrect data. There is no add or modify button that you need to press. As soon as you move off a field, the data in that field is saved. If the system is waiting for you to complete the field before it writes the data to the database you will see a pencil displayed. When the data is saved, the pencil will disappear. The example below indicates that the system is waiting for you to move off the op code field. To delete a row of data, you must highlight that row and press the delete key on the keyboard. Before you can delete a row, the data must have been saved. i.e. the pencil must not be displayed. Page 19 of 34

20 Tips Activating a List There are fields that look like text boxes but are actually list boxes. The list box arrow is not activated until you click on the far right hand side of the field. When the arrow appears you can select the relevant item from the list. Page 20 of 34

21 Tips Order of Entry When you see a data entry set like the one below, it is best practice to work from left to right completing each row before you start the next row. If you don t work left to right, known bugs exist that may pop-up erroneous error messages. In this example, enter an operation code, then the related diagnosis for that operation code. Then enter the next operation code and related diagnosis. Page 21 of 34

22 Tips Related Diagnosis MDAnalyze does not allow you to have the same operation code and diagnosis entered more than once. For example, if the same procedure is done bilaterally the operation code is entered twice with a diagnosis representing each side as shown in the example below. Page 22 of 34

23 Tips Billing Codes MDAnalyze allows you to enter billing codes for an admission and an operation. The billing codes in MDAnalyze are the CMBS codes from Medicare Australia and the same version of the billing codes used by the RCH. They are updated periodically to coincide with the new CMBS releases from Medicare. Billing codes can be associated with an operation and an admission. The same billing code can be added multiple times to an operation. An example of the billing codes for an operation is shown below. For an admission, a billing code is associated with a procedure (see the example below). Please note that ORMIS, or HASS as it is commonly known is the RCH Theatre Scheduling System and the billing codes must be entered in ORMIS. Page 23 of 34

24 Tips Templates Standard templates can be created to save the user having to enter the same information repeatedly. A template can be created for a note field so you can create a template for a clinic visit note, an admission note and an operation note. The creation of templates is a secured function, so contact your departments MDAnalyze administrator to discuss creating a template. To active a template click on the open folder icon as shown in the screen shot below. Another screen will open allowing you to select the appropriate template. When you press the Ok button on this screen the text from the template will be copied to the notes field. Remember that when you press the Ok button, any text already in the notes field will be overwritten with the text from the template. If you want to keep the existing text, you must copy and paste the text from the template to the notes field by using the standard copy and paste commands. Page 24 of 34

25 Tips Known Bugs There are several known bugs in MDAnalyze that the vendor will be addressing in subsequent releases. They are: Not all rows are exported in the Search and Analysis function If more than 500 rows are returned from one of the queries you run in the Search and Analysis function and you export that data only the first 500 rows are exported. To over come this, use the scroll bar on your results set to scroll to the bottom of your results, then export. The Print All button on the print preview screen closes the report without printing If you press the Print All button on the print preview screen, the report will close without printing. To avoid this, use the print icon on the print preview screen to print. Page 25 of 34

26 Other Features Chapter 5 Other Features Custom Forms A custom form is a screen that pops-up and captures information relevant to a score type, diagnosis or operation code. MDAnalyze has the ability to create custom forms that are activated when: A score type is associated with an admission or clinic visit A diagnosis is added and a specific diagnosis code is selected An operation code is selected The table below shows the custom forms that are currently available for use. department can decide to use none, one, many, or all of these forms. A If you want to discuss creating a new form, contact your MDAnalyze department administrator. Custom Form Ankle-Hind foot Scale Description Calculates a score based on a series of questions such as activity limitations, max walking distance, gait abnormality etc. Body Index Mass Calculates the BMI based on height and weight. Botox Dosage DASH Hip Arthroplasty Knee Arthroplasty Pirani Classification Scoliosis Captures the botox dosage for individual sites in the upper and lower limbs. Calculates a score based on a series of questions related to disabilities of the arm, shoulder and hand. Caputres various information about a hip arthoplasty procedure such as surgical approach, DVT Prophylasix, AB Prophylasix. Caputres various information about a knee arthoplasty procedure such as surgical approach, DVT Prophylasix, drains, tourniquet etc. Calculates a score based on the Pirani Classification. Captures a range of values in degrees and cms such as cervical scoliosis degree, shoulder elevation in cm and rib hump in degrees. Short SF12 v2 Form Calculates a score based on a series of questions about the patients health. Page 26 of 34

27 Other Features Custom Form Description Short SF36 v2 Single Multi Surgery Form Event Level Calculates a score based on a series of questions about the patients health. Indivates what soft tissue and bony procedures where carried out during a SEMLS operation. Spinal Implant Captures the type and size of spinal implants used at various levels. SRS30 Surgery Calculates a score based on a series of questions about a patients liefstyle post surgery for scoliosis. SRS30 Surgery Post- Pre- Calculates a score based on a series of questions about a patients liefstyle prior to surgery for scoliosis. Wong-Baker Faces Pain Scale Captures a score based on the pain level expressed by the patient. Page 27 of 34

28 Other Features Search and Analysis Function A reporting function exists in MDAnalyze that allows you to create and run your own queries. You can view, print or export the results of your query. Click on the Analysis icon on the main menu to display the Searching and Analysis screen. You can re-run an existing query, create a new query or just view the results of a query that has already been run. To create a new query, press the New button. To indicate that you are the owner, append your initials to the start of the query name. If you sort the list, you will then see all your queries listed together. This should also prevent others from changing your query. A list of data will then be displayed. Use this list to construct your query. Once you have built your query, press the Run button. The results of your query can be viewed by clicking on one of the icons listed on the left side of the screen. For example, clicking on the Admissions icon will display the admission details that meet your criteria. To re-run an existing query, highlight the query in the list and press the Run button. The date the query was last run is displayed in the search list. If you don t press the Run button the results you see will be the results as of the date last run. To export the results of your query, right click your mouse when viewing the data you want to export then follow the prompts. Note: See the section on Known Problems for an explanation of a problem that exists when exporting data. Page 28 of 34

29 Other Features Log Book Surgeons can utilise the Search and Analysis function to create a query to return all operations which they took part in. They can then print a report or export the data to a.csv file that can be loaded into MS Excel for further analysis. To create a logbook, create a new query and then select the surgeon from the tree view. Click on Operations, Summary then Surgeon (1). Then press the run button to execute your query. You can then press the Operations button (2) and then export the results. 1 2 Page 29 of 34

30 Other Features Media Centre This feature allows you to store documents, videos, clinical images and other forms of media. A media item can be associated with a patient or with a specific operation, admission or clinic visit. For example, clinical images of an operation should be associated with that operation. To view all media items associated with a patient, click on the Media icon on the main menu as shown below. You can associate a media item with an operation, clinic visit, diagnosis or admission. If you need to associate a media item with a patient, not a specific admission, operation etc, add the media item via the patient demographic screen. This example explains how to associate an image with an admission. Select the admission then press the Add Media button. Page 30 of 34

31 Other Features The example below shows how to add an image. Click the type of image you want to add and then right mouse click the icon. The example below shows how to add an image. To add a single image, select Add Image. To add multiple images, select Add Image Set Page 31 of 34

32 Other Features Create a meaningful name for your set (1). To select the images you want to add, press the button next to Directory (2) to locate the appropriate folder. The files that are images in the folder you select will be displayed in (3). Select the appropriate files to add. Add text to the Notes field if required; select the hospital, type of media and the date, then press the Ok button Page 32 of 34

33 Other Features Reporting Periodic Reporting Two reports have been customised for the RCH. They are the Admissions Report and the Complications Report. To run these reports, select the icon indicated on the screen shot and then the appropriate report. The Admissions Report shows all admissions and operations with a date that falls within the specified date range. The Complications Report shows all complications with a date that falls within the specified date range. Page 33 of 34

34 Other Features Patient Level Reporting To print a report based on the patient you have displayed, select the Reports option from the main menu. For example the Operations Report will print all the operations for the patient; the Admissions Report will print all the admissions for the patient. Page 34 of 34