Making the Transition to Computerized Medicine Medicine is information intensive Technology is available to us now Time to take advantage of it Success = Improved Efficiencyi Failure = Frustrating and Expensive 2 Standards for Conventional Written Records Electronic Health Records Legal Ramifications One Proposed Solution The vast majority of business transactions are still done on paper. Forensic Document Examiners validate the paper and ink of the written instrument. These individuals are called upon to offer expert testimony on the authenticity of questioned documents. 3 4 A person may simply desire to correct a recording error, such as reversing two digits in a temperature recording. Someone may be attempting to alter a record to conceal a mistake or failure to provide proper care. While there is absolutely no justification for record alteration for simple concealment, it makes perfect sense to allow for correction of errors in notation. 5 6 Practice Builder 2010 1
This avoids misleading the reader of the record with an erroneous entry. The proper practice in these instances is to note the error and the correction on the face of the record (where the error was present). This could be accomplished by line through with accompanying notations in the margins or additional sheets. As long as the reader can understand what was originally written, what it is being replaced with, and the reason the replacement is being made, there is no case for concealment. Whiteouts or replacement of pages would not be permissible, as it would destroy the original notation. 7 8 Standards for Conventional Written Records Electronic Health Records Legal Ramifications One Proposed Solution All of the basic rules regarding the medical records in hard copy also apply to those in electronic formats. The care provider is responsible for maintaining the integrity of the record with respect to alterations. When questions of alterations arise, electronic records pose special problems that need to be considered. 9 10 Electronic entries may be constantly subject to alteration, depending on the software program that is utilized to generate and store the information. Although software can be created to prohibit any alteration after even a single keystroke is made, this would most likely be unacceptable to most people. The record could be produced using line through text when typographical errors are produced, but reading such a record would be very difficult. 11 12 Practice Builder 2010 2
Software programs may allow a certain period of time for entries to be changed before protecting them from alteration, or may allow a user to authenticate an entry and protect it at a later time. One pitfall to authentification systems would be the failure of the author to authenticate some of his/her entries. Standards for Conventional Written Records Electronic Health Records Legal Ramifications One Proposed Solution 13 14 The legal system has been slow to recognize the use of the electronic health record by the healthcare community. Most states have not enacted any comprehensive rules and regulations governing the issues of computerized medical records. Since the technology is constantly evolving, writing a comprehensive code to deal with all the possible issues and problems is currently hard to fathom. Using existing law results in a situation where you have extremes in flexibility and inflexibility when dealing with the electronic record. 15 16 Most states contain some provision in their evidence code that allows a "non erasable optical image reproduction" that is created and preserved in the regular course of business. In that case, a court can accept a hard copy printout of the records from the computer system. Standards for Conventional Written Records Electronic Health Records Legal Ramifications One Proposed Solution 17 18 Practice Builder 2010 3
Hospitals utilizing computerized records must maintain the integrity of the medical record and must generally safeguard against loss, defacement, and tampering or unauthorized use. To safeguard against loss, the hospital must maintain the record in a separate area that is safe from human hazards such as theft and natural hazards like flood and fire. 19 20 Creation of a complete archival backup of the record system on a regular basis is a must. Storage of this backup with a bonded third party record storage facility is one very responsible option. This data could be written to optical storage media (such as a compact disc or similar media), and then stored off site. When a bonded dthird party is involved, the chain of custody of that information is much more solid. 21 22 23 24 Practice Builder 2010 4
If the storage media is picked up from your hospital by a courier of the records storage company, they will note the time and date of the pickup and return the media to the records storage facility, where it will be placed in your container. This off site storage facility protects your data against loss from a disaster, but also serves as a check against tapering and record fraud. If a regulatory agency (such as a State Board of Veterinary Medical Examiners) or courts should request your records, your printout from the computer system would be your first submission. 25 26 If the legitimacy of those records is called into question, the appropriate agency or court could be granted access to the archival copy at the records storage facility. Once they retrieve the media and compare the contents of the record in question, they should be satisfied that nothing has been altered. The archived data should contain provisions for the data to be viewed when it is restored to another computer (i.e. a copy of the electronic records management program with the correct version for viewing the data should be included or available). 27 28 Since the records called into question are often many months or years after the care has taken place, the archival storage of the record very soon after it was created (such as 0 14 days after the alleged incident) should be reasonable proof that you have not since altered the record in any way. In the case of an adverse event (such as a patient death), after the record is completed, an archive of the system should be made immediately and stored off site. 29 30 Practice Builder 2010 5
State Veterinary Medical Boards realize that the computer is here to stay. They are most interested in making sure that quality patient care is delivered and the public is safe. I am not aware of any court cases presented thus far where computerized medical records were the only evidence presented. In time, this will probably happen and then the courts will have to decide what to do... I am sure that none of you wishes to be the ground breaker there! 31 32 1. We need to see who said what and when; the medical records need to be complete. 2. They need to be protected from alteration after the fact. Yes, paper records can be altered after the fact there are paper and ink experts that are called on to testify in such cases as to the age of the paper/ink, etc. on the page as to alterations. The fear is that the computer records would be altered and the "evidence" would be gone. 33 34 We need some way to prove that what is contained in Fluffy's record at 7:00pm this evening is the exact same thing when viewed in January of 2009. Here is just one way to do that.... At the end of January your data and program were backed up onto a CD/DVD. That disc was stored off site with a company in a records warehouse in bonded storage. A courier came and pickup up the disc at your hospital, you signed it in on the log and the courier logged it in at the warehouse. The warehouse maintains security of their establishment and they vouch for the fact that you have not touched that disc since it left your office in January of 2009 The State Board asks to see your records about a dispute the client has about Fluffy's care back in January of 2009. You print out the records in your system at the office and present them to the Board. They want to be sure that you didn't "doctor" the record. You give them written permission for the investigator to obtain the CD/DVD from the storage facility (you do not go get it yourself!) as evidence you have not altered the record it contains the exact same data regarding the incident. This is the safest way I know possible and involves a neutral, bonded, third party. As far as "inalterability" of most programs on the market for us today the data could probably be altered in some way. The above scenario would be a good safeguard. The money you used to spend on printing costs now goes into CD/DVD storage. 35 36 Practice Builder 2010 6
Stephen Pittenger, DVM, DABVP Friday, Okay what if your network goes down? Yep, you guessed it, you need safeguards for that as well. This is the hardware/software side of things you probably cannot over prepare for a disaster such as this, but you can definitely under prepare. Technology exists to prevent ANY downtime; it just requires more money to achieve this state. state In the computer industry, industry this is called fault tolerance. fault tolerance You can guard against a hard drive crash with a "mirrored" hard drive. You can also mirror the data to other machines on your hospital network. Battery backups/surge protectors can provide power during brief outages and protect against spikes in electricity. BACK UP! 37 38 39 40 41 42 Practice Builder 2010 7
43 44 45 46 47 48 Practice Builder 2010 8
49 50 Always buy and sell in the same unit of measure (capsule, tablet, ml) Order Pack is useable only when the qty is ALWAYS in that size (e.g. 500 capsules/bottle) I prefer to ignore it. I use inventory as inventory, treatments as treatments PERIOD. Inventory used is only used to piggyback consumables to treatment applications. Making the most of a little time together in the outpatient setting 51 Clients like to come in and get out, but have a pleasant experience. Our hospital income is limited by how many cases we see per day. Less income means less staff $$$ Happy clients means constant supply of $$$ for happy staff Rotate Inpatient to Outpatient and vice versa in the afternoon. Float Doctor can cover either on odd number doctor days. Each doctor has one Administrative afternoon per week to try to catch up on reading, projects, etc. 53 54 Practice Builder 2010 9
Inpatient team runs white boards, surgical cases, covers emergencies and when the outpatient staff is fully booked, also covers walk ins. Outpatient team handles all outpatient appointments. Float staff personnel can cover either area as needed. Rotational schedules set up so that there is no monotony. Fair and balanced workloads. Similar inpatient v. outpatient loads Rotation of days of the week (so as not to have the same person seeing Monday morning appointments every week). 55 56 Schedule by rooms, not by doctors Follow the dentist example multiple chairs and support staff for one doctor. Increase schedule density as efficiency gains are made and the staff can handle the workload 57 58 59 60 Practice Builder 2010 10
Room I Room II Room III 9:00 XXXXXX 9:10 XXXXXX XXXXXX 9:20 XXXXXX XXXXXX 9:30 XXXXXX XXXXXX 9:40 XXXXXX XXXXXX 9:50 XXXXXX XXXXXX 10:00 XXXXXX XXXXXX 10:10 XXXXXX 10:20 Room I Room II 9:00 Nurse 9:05 Nurse/Assistant 9:10 Doctor/Assistant Nurse 9:15 Nurse Doctor 9:20 Doctor/Assistant 9:25 Doctor 9:30 Nurse A human body can only be in one room at a time. Computers in the rooms are used for data entry in real time. Client not dismissed to go up front until medical record (and charges) are complete. We work as a TEAM T Together E Everyone A Achieves M More W Willingness O Organization R Respect K Kindness 63 64 A TEAM is only as strong as its weakest link. Training is the key to success. Analyzing the Game Film shows you what to train on next or what to refine. 65 66 Practice Builder 2010 11
Nail Trims Blood Draws No exam/problem Anal Sac Expression Suture Removal Annual Exams Uncomplicated Medical Progress Exams Minor Problem 67 68 Medical Progress Complicated Problem Major Problem New Client Annual Examination Two Patient Annual Exam Exotics Established/well; Minor Problem New Client Second Opinion Annual Exam Complicated Three Patient Annual Exam New Client Complicated Problem Exotics New (sick, well) and established ill patients Outpatient Labs/Radiographs 69 70 Appointment Reception Exam Room Nurse Nurse & Assistant Nurse briefs Doctor Doctor & Assistant Doctor Doctor briefs Nurse Nurse Discharge Reception TEAMWORK means that we all play an integral part in the process of delivering highquality care to our patients and clients. The RIGHT hand must know what the LEFT hand is doing or is about to do. Anticipation of the needs of the Patient, Client and Doctor is a major portion of your day. 71 72 Practice Builder 2010 12
Client telephones Pertinent information about the chief complaint is logged. An appointment is booked. Receptionist greets client. Receptionist confirms chief complaint and asks if any further problems are to be covered. Receptionist directs client to the appropriate exam room. Receptionist prints last two visits and places them in the back of the door alerts the nursing staff. 73 74 Nursing staff identifies the client, patient and problem(s). Any pertinent history that needs to reviewed before room entry done at a workstation. Necessary supplies are collected and the room is entered. Assistant either enters with the nurse or is on call. 75 76 Nurse takes a brief history. History can be General or Problem specific. Notations are all made in the medical condition record area. 77 78 Practice Builder 2010 13
Stephen Pittenger, DVM, DABVP Friday, Nurse takes vitals, performs nursing examination. Assistant restrains animal for the Nurse. Necessary treatments are either completed in the room or the animal is transported to the treatment area for more in depth treatments. Medical condition record is closed. Log off. Room is prepped for the doctor. Assistant stays with patient, nurse exits. 79 80 81 82 83 84 Slide for aspiration of impression cytology Practice Builder 2010 14
Nurse locates appropriate doctor and briefs doctor on the case. Name, signalment, chief complaint, pertinent history, vitals and exam findings are verbally communicated to the doctor. Doctor enters the room and proceeds with either further history gathering or begins examination. Assistant continues restraint. Patient is released to owner. Treatments are ordered. Assistant exits the room. 85 86 Assistant and/or Nurse begins to collect appropriate treatment items, medications, handouts, etc. If Doctor is going to discharge, assistant takes materials to the doctor. If Nurse is to discharge, assistant collects materials for the nurse and briefs nurse on doctors orders. 87 88 Nurse and Doctor briefly confer about case. Follow up (Recheck appointment, Follow up or Reminder) is documented. Nurse discusses instructions with the client. Nurse communicates the follow up needs for the patient to the client. Nurse completes record keeping (including follow up). Nurse either presents invoice to the client in the room, has receptionist present the invoice in the room, or has the client leave the room and report to the discharge desk kfor invoicing, whichever is client's preference. Once the room is vacated, nurse or assistant cleans the room for the next patient. 89 90 Practice Builder 2010 15