Tung Nguyen BHIM/BHS (LaTrobe) BOSSnet Victorian Account Manager Direct Data Entry e-Forms: the bridge between scanned records and the paperless hospital Tung Nguyen BHIM/BHS (LaTrobe) BOSSnet Victorian Account Manager

Agenda Introduction The current situation: Paper based forms in a scanned record The solution: Electronic Forms Why use e-Forms? - Issues - Aspirations & reality - Costs & Benefits Key messages Transcription requirements (simple versus complex) General discussion and questions

Introduction – who am I? Health Information Manager. Worked across four tertiary health services that have implemented a scanned medical record solution. Currently managing a Digital Medical Record.

The current situation: Paper forms in a scanned record Used to record diary-like statements of work and treatment outcomes for clinicians. Recognised issues with timely access (scanning backlogs), storage and retrieval. Need to document the same data in multiple times on multiple forms. Limited ability to collect and share data in a standardised format. Readability issues of handwritten forms. The current situation: Paper forms in a scanned record

The solution: Electronic Forms Data collection tools. Input can be simple (e.g. free text and drop down boxes) or complex (e.g. abstracted from other clinical tools and systems). Have the ability to output the data in various ways to assist clinical care (e.g. graph points on a growth charts). Enable point in time data collection.

Issues & Considerations Change management - attitudes & behaviours - Planning Identify workflows that do not currently exist. Start with small steps (e.g. simple transcription e-Forms in a targeted department). Consider adopting shared terminologies and concepts (e.g. ICD-10-AM). Work towards reducing and eliminating the issues caused with written forms.

Costs A clinical system needs to be in place to support e-Forms. Sufficient availability of clinical access devices. - Clinical drive for mobile devices due to advancements in technology (e.g. smart phones and iPads). Clinical buy-in from stakeholders. Operational and ongoing support.

Benefits Improve data readability (for accurate diagnoses, referrals, assessments, care plans etc). Collect standarised data to improve service quality through research, billing and State/Federal minimum data sets. Instant storage and access to patient data in real time (no delays in scanning). Linkage to clinical systems, protocols for decision support. Enables data to be manipulated and displayed in different formats. You are in control of the data.

The reality of using e-Forms Changes to attitudes and workflows take time, however there is a great push from clinical teams to implement direct data entry e-Forms . Health services must ensure the demand for e-Forms is met with the supply of sufficient clinical access devices. Requires buy in from all stakeholders. Requires process/work flow redesign.

Simple e-Forms Examples include: - Admission forms - Coding sheet - Questionaires Used to tidy up existing paper forms. Allow clinicians to ease into the change from hand writing to direct data entry. Immediate benefits seen.

Complex e-Forms Examples include: - Discharge Summaries - Progress Notes - Growth Charts Should integrate with other tools to provide a complete picture of episode of care. - Medication Management (allergies and contraindications) - Results (Pathology & Radiology) - Pharmacy (inventories) Provide clinical decision support.

Summary The ultimate goal for a clinical environment should be paperless. Change requires time and planning. Consider the use of standardised terminologies and concepts. E-Forms should be able to share data with other clinical systems and tools.

Tung Nguyen BHIM/BHS (LaTrobe) BOSSnet Victorian Account Manager Email: tung.nguyen@coremedicalsolutions.com Phone: 0403 616 948 Website: www.coremedicalsolutions.com