him india info - 2015...him india info - 2015 1 contents day - 1 program schedule 2 day - 2 program...

Venue

Krishna Insti tute of Medical Sciences Ltd.# 1-8-31/1, Minister Road, Hyderabad, India

SOUVENIR

with Theme BETTER HEALTH INFORMATION MANAGEMENT

FOR BETTER HEALTH CARE

HIM INDIA INFO - 20154th - 5th December 2015

Sponsors :

Health Informati on ManagementAssociati on (HIMA) INDIAconducted 1st Nati onal Conference and Exhibits on HIM and IT under the guidance of Organizing Chairman, Dr. G. D. Mogli, PhD, MBA, FHRIM (UK), FAHIMA (USA)

In collaborati on with


Veiled Rebecca, Salarjung Museum

NTR Garden

Golconda

BirlaMandhir

Cyber Tower

Shilpa Ramam

HIM INDIA INFO - 2015

1

ContentsDAY - 1 Program Schedule 2DAY - 2 Program Schedule 3(HIMA) Organizing Committ ee 4Messages 5Strategic Role of Nati onal HIM Associati on of Developing Countries in 21st Century 16eyeSmart EMR – Doorstep to Boardroom 22Medical Records Diploma Educati on Program in Kuwait 24Health Informati on Management’s Professional Role in Effi cient Management of Health Informati on in USA 27Innovati on in Medical Records Department 31Electronic Medical Record 33Health Informati on Management Professionals 36Health Informati on Exchange: An Overview of Improving Health Care & Pati ent Safety 41Transformati on of Healthcare with Electronic Health Records (EHR) Opportuniti es and Challenges 45Challenges of HIM Professionals with Emerging Technology and Reimbursement Models 47A study on the administrati ve delays in the pati ent discharge process and subsequent reducti on achieved aft er implementati on of Pre discharge planning in a Terti ary Care hospital in South India. 51Diff erence between ICF & ICDIO Codeing 55Medical Legal Aspects of Electronic Health Records (EHR) from HIM Perspecti ve 57Problem Oriented Medical Record 63Tips for Evaluati ng the Pre-Implementati on of ElectronicHealth Records Soft ware 65Standards of Nursing Practi ce in USA 69Doctors and Nurses Records Documentati on 78Health Informati on Management and Pati ent Safety 80“An Innovati ve Approach to Hospital Staff Accountability” 82Medical Records Present and Future Scenorio 84E.H.R Functi onal Requirements Specifi cati ons 86Retenti on and Preservati on of Medical Records-Paper and Paperless 90Organizati on of pati ent care in the ward 95Medical Records Audit Helps in Improvement of Pati ent Care 98Medical Audit 102

Health Informati on Management Associati on (HIMA) INDIA1st Nati onal Conference on HIM & IT

HIM INDIA INFO-2015with Theme

BETTER HEALTH INFORMATION MANAGEMENT FOR BETTER HEALTH CARE4th - 5th December 2015 at KIMS Hospital, Hyderabad

Medical Records Diploma Educati on Program in Kuwait 24Health Informati on Management’s Professional Role in Effi cient Management of Health Informati on in USA 27Innovati on in Medical Records Department 31Electronic Medical Record 33Health Informati on Management Professionals 36

Emerging Technology and Reimbursement Models 47

aft er implementati on of Pre discharge planning in a Terti ary Care hospital in South India. 51Diff erence between ICF & ICDIO Codeing 55Medical Legal Aspects of Electronic Health Records (EHR) from HIM Perspecti ve 57

Souvenir_Book.indd 1 12/2/2015 3:37:35 PM


2

Health Information Management Association (HIMA) INDIA1st National Conference on HIM & IT



DAY - 1 PROGRAM SCHEDuLEFriday 4th December, 2015

Time Topic Presenter08.00 - 09.00 am Registration09.00 - 09.50 am Inauguration09.50 - 10.20 am Coffee break10.20 - 10.40 am Strategic Role of National HIM of Developing

Countries in 21st CenturyDr. G. D. MogliHyderabad, India

10.40 - 11.00 am Eye smart EMR Doorstep to Boardroom Dr. Anthony Vipin DasHyderabad, India

11.00 - 11.20 am Medical Record Diploma Education Program in Kuwait

Dr. Saadoun Faras AlAzmiKuwait

11.20 - 11.40 am Group Discussion (Moderator: Dr Saadoun Faras Al Azmi)11.40 - 12.00 noon HIM Professionals role in Effective Management of

Health Information in USADr. Jayachand PallekondaUSA

12.00 - 12.20 pm Innovation in Medical Records Ms. Prabha, Hyderabad, India12.20 - 12.40 pm EMR Status in AIIMS Mr. R. K. Kaul, New Delhi, India12.40 - 01.00 pm Group Discussion (Moderator: Dr. Jayachand Pallekonda 01.00 - 02.00 pm Lunch break02.00 - 02.20 pm HIM Professionals current status and future

prospectsMs. Raniya Humaid M. Al-KiyumiAustralia

02.20 - 02.40 pm Health Information Exchange An Overview of Improving Health Care and Patient Safety

Mr. Madhu MohanMumbai, India

02.40 - 03.00 pm Transformation of Health care with EHR –Opportunities and Challenges

Mr.Zakir HussainHyderabad, India

03.00 - 03.20 pm Group Discussion (Moderator: Ms. Raniya Humaid M. Al Kiyumi03.20 - 03.40 pm Coffee Break03.40 - 04.00 pm Challenges of HIM Professionals with Emerging

Technologies and Reimbursement MethodsMr.Narendar Sampth kumarDubai, UAE

04.00 - 04.20 pm Delays in the patient discharge process Dr. N. Lakshmi Bhaskar and others Hyderabad, India

04.20 - 04.40 pm Difference between ICF & ICD-10 Coding Mr. I. T. KallesharaMumbai, India

04.40 - 05.00 pm Group Discussion (Moderator: Mr. Narendar Sampath Kumar)06.30 - 07.30 pm Meeting of the representatives of different states/countries to elect the Board

Directors as policy makers to oversee the HIMA India and how it can move forward to make vibrant national association to conduct international congress in the year 2017 or holding IFHIMA International Congress in 2019. Meeting members and venue will be notified on 4th December, 2015.



3

Health Information Management Association (HIMA) INDIA1st National Conference on HIM & IT



DAY - 2 PROGRAM SCHEDuLESaturday 5th December, 2015

Time Topic Presenter08.00 - 09.00 am Break Fast09.00 - 09.20 am Medical Legal Aspects of Electronic Health Records

from HIM PerspectiveDr. G. D. MogliHyderbad, India

09.20 - 09.40 am Problem Oriented Medical Record Prof (Lt Col) Dayakar ThotaHyderbad, India

09.40 - 10.00 am Tips for Evaluating the Pre-Implementation of Electronic Health Record Software

Vikky N D VikramQatar

10.00 - 10.20 am Group Discussion (Moderator: Prof(Lt Col) Dayakar Thota)10.20 - 10.30 am Sponsor - Crown - Records Management10.30 - 10.40 am Sponsor - Suvarna - Technosoft10.40 - 10.55 am Coffee Break10.55 - 11.15 am Standards of Nursing Practice in USA Mr. Daniel Williams, USA11.15 - 11.30 am Doctors and Nurses Record Documentation Mr. Eben Jeya Roy

Puducherry, India11.30 - 11.45 am Health Information Management and Patient Safety Mr. D. M. Joseph

Bangalore, India11.45 - 12.00 noon Group Discussion (Moderator: Mr. Daniel Williams)12.00 - 12.15 pm An Innovative Approach to Hospital Staff

AccountabilityDr. P.SatyanarayanaHyderbad, India

12.15 - 12.30 pm Medical Records Present and Future Scenario Mr. Vijaya KumarMysore, India

12.30 - 12.45 pm Electronic Health Record Functional Requirements Mr . BalasubramanianTN, India

12.45 - 01.00 pm Group Discussion (Moderator: Dr. P.Satyanarayana)01.00 - 02.00 pm Lunch break02.00 - 02.15 pm Current Challenges in Information Management Lt. Col (Dr) Kamalakar

Hyderbad, India02.15 - 02.30 pm Retention and Preservation of Medical Records -

Paper and PaperlessDr. G. D. MogliHyderbad, India

02.30 - 02.45 pm Medical Audit Dr. (Lt. Col) N.K SarangiHyderbad, India

02.45 - 03.00 pm Group Discussion (Moderator: Lt Col (Dr) Kamalakar 03.00 - 03.30 pm Panel Discussion (Members from other states)03.30 - 03.45 pm Coffee Break03.45 - 04.00 pm Distribution of Certificates to Delegates04.00 - 04.30 pm Conclusion and Closing Ceremony



4

(HIMA) Organizing CommitteeOrganizing Chairman : Dr. G.D Mogli, Sr. Consultant eHealth Management, Health Care advisor

Organizing Secretary : M. Subhakar, Manager – HIM, Apollo Hospitals, Jubilee Hills, Hyderabad

Joint Secretary : Sunil Reddy, Asst. Medical Record Officer KIMS

Treasurer : Kishore Babu, Medical Records Officer, LVPEI Hyderabad

Scientific Committee : Dr. G D Mogli, Sr. Consultant eHealth Management, Health Care advisor

Sanna Veerabhadrappa, Retd. Sr. Medical Record Officer, Bellary

Mahesh Babu, Medical Record Officer, HOD Rajiv Arogya Sri NIMS, Hyderabad

M. Madhu Mohan, Medical Record Officer, Tata Memorial Hospital, Mumbai

HIM Executive Members : D. Prabhakar, Sr. Medical Record Officer, Yashoda Hospital, Hyderabad

B. Kumar, Sr. Medical Record Officer, Kamineni Hospital, Hyderabad

Mohd Zakir Hussain, Sr. Medical Record Officer, BIAHRI, Hyderabad

Ramakrishna, Medical Records Officer, ESI Hospital, Hyderabad

E. Sudhakar Raju, Medical Record Officer, Citizen Hospital, Hyderabad

P Vidhya Sagar, Medical Record Officer, Medicity Medical College, Hyderabad

V. Narender, Asst Manager Apollo Medical College, Hyderabad

Shaik Abdul Rehman, Executive, Apollo Hospitals, Hyderabad

Y Ramesh, Executive Apollo Hospitals, Hyderabad

Resource Members : Bala Subrahmanyan, CMC Vellore, Tamil Nadu

Y. Eben Jay Roy, JIPMER, Pondechery

Vijay Kumar, Bellary

R. K. Kaul, AIIMS New Delhi

I. T. Kalleshara, AYJNIHH, Mumbai

D. M. Joseph, St. John’s, Bangalore

Bossar M Raja, St. John’s Bangalore

Pratapan CP, Apollo Hospital, Secunderabad

Venkatesh, Continental Hospital, Hyderabad

Gunta Sen Verma, KIMS Hyderabad

G J Rakesh Kumar, KIMS, Hyderabad

Mrs. Santhi Joel, KIMS Hyderabad

Sunil Raghava, KIMS Hyderabad

Khaleel Ahmed, KIMs Hyderabad

uma Maheswar Rao, KIMS, Hyderabad

Mrs. M. Bharathi, KIMS, Hyderabad

Dr. Naga Sindhu, Yashoda Hospital, Hyderabad

Mrs. Srungaram, KIMS Hyderabad

Tabitha, KIMS Hyderabad

Mallik John, ESI Hospital, Hyderabad

Bhaskar Reddy, BTIACRC, Hyderabad

K. Vikram, Lotus Hospital, Hyderabad

Raghavendra Reddy, Apollo Hospital, Hyderabad



5



6

Prof. Kakarla Subba RaoFRCR, FACR, FICP, FSASMA, FCCP, FICR, FCGPChairman - KIMS Foundation and Research CenterChairman - KREST RADIOLOGYFormer Director - NIMS, Hyderabad

MESSAGE!

I’m glad to know that the First National Conference by Health and Information Management Association (HIMA) India, is organized at Hyderabad. Hyderabad has become a medical and health hub of India. National and International speakers are participating in this event.

World Health Organisation (WHO) has defined health as not only devoid of disease but having social, emotional, moral and spiritual well being. Keeping this in view, information, knowledge and wisdom are necessary for health care professionals. This conclave aims at enlightening the delegates with regards to the knowledge of technical advances in keeping electronic health records and maintaining international standards in hospitals.

Healthcare management is a specialised profession which is essential for Govt. medical institutions, corporate hospitals and nursing homes. Today, medicare has become quite costly for the middle class as well as the poor class. Although, various Govts. Schemes are there for people below poverty line, they are neither adequate nor satisfactory. I hope, this conference deals with universal health insurance schemes as well as looking at accessibility, availability, affordability and high quality health care for the population. Managing finances, personnel and equipments is a serious task and involves skills, attitudes and aptitudes. Here I must say that health care managers should possess basic knowledge of health and diastase. Ultimately, safety of the personnel and patients is important.

I’m sure the papers presented will be innovative and cost effective.

I wish the conference a great success

Prof Kakarla Subbarao



7

Dr G D MogliPhD MBA FHRIM (UK) FAHIMA (USA) President HIMA India and Organizing Chairman, HIM INDIA INFO-2015

It is with great pleasure we welcome Health Information Managers and other related healthcare professionals across India and overseas to the 1st National conference being conducted by Health Information Management Association (HIMA) India from 4th to 5th December, 2015 at KIMS, Hyderabad, India with theme “Better Health Information Management for Better Health Care”.

It is said that the history of medical records run parallel with the history of medicine. In the growth of medicine, medical records have played an important role as a tool and as a basis for planning patient care, providing a means of communication between the doctor and other professional groups contributing to the patient’s care; furnish documentary evidence of the course of illness and treatment of medical care rendered.

In the year 1902 at a convention of the American Hospital Association discussed for the first time to bring improvement for records by training record librarians. In 1905 at the 56th annual meeting of the American Medical Association presented a paper entitled “A Clinical Chart for the Records of patients in small hospitals”. And in 1913 American surgeons wanted to raise standards of surgery for which patient data was needed for the training purpose.

In the year 1928, Mrs. Grace Myers conducted a meeting to discuss medical record problems in Boston, for which the medical record workers from USA and Canada participated, at this juncture formed the Association of Record Librarian of North America with the objective to elevate the standards of clinical records in hospitals and Mrs. Myers was elected as first president.

In 1934 Elsie Royle, of UK with the help of others formed an Association of Medical Records Officers (AMRO) in UK. The first International Congress on Health Records was held in London in 1952. Most significant landmarks in medical record science resulted in Organization of national medical record associations, the USA (1928), Canada (1942), Great Britain (1948), Australia (1952) and India (1972) and so forth

The International Federation of Medical Records (IFMR) was formed in Stockholm, Sweden in 1968, and later named as The International Federation of Health Records Organizations (IFHRO) which was initially recognized by the WHO in 1968 and invited to participate in the first World Study Group on Hospital Records in Geneva, Switzerland in November 1969.

Dr. G. D. Mogli, with the support of senior professionals from all over the India, formed the Medical Record Officers Association at the JIPMER, Pondicherry on 12th July 1972. By 1976, there were 67 registered members. The Association was granted active membership of International Federation of Health Records Organizations (IFHRO) in September 1976. To keep in line with IFHRO, the association’s name was re-named as “Indian Association of Health Records” from 9th December, 1977. It had four state branches located in Bangalore, Hyderabad, Madras and Pondicherry.

Objectives of National Association: is to • Establish a central HIM department in the Ministry of Health to be headed by a senior

• HIM professional to oversee the development of HIM programs in the county

• Setting of national standards for medical records / health information management



8

• Improve the quality of HIM professionals and HIM numbers

• Initiating HIM educational and training programs to generate needed manpower

• Conduct workshops, seminars and conferences for the benefit of HIM and institutions.

• Develop HIM policies and procedures including, the budget, staff pattern etc.

• Participate and assist the government in improvement of healthcare delivery system

• Develop partnership with IFHIMA and similar associations to enhance the HIM status

• Strive to advance the eHealth technology to meet dynamic progress of medicine for the nation

Conclusion: with the advent of technology and communication system, the global nations have to be closure, hence, all the developing countries, should become members of the IFHIMA to avail the facilities it provides through international integrated work by designing, developing and conducting the educational programs for the benefit of member countries. The priority for any country would be to serve the nation by bringing together, the professionals’ establish a national association, if not existed, and get affiliated with the IFHIMA. The IFHIMA should also coordinate and cooperate by active participation with the nations mainly developing countries.

We humbly welcome you to Hyderabad – enjoy the congress and milieu.



9

Dr. B. Bhaskar RaoMD & CEOKrishna Institute of Medical Sciences, Hyderabad

It gives us immense pleasure to associate with Health Information Management Association (HIMA) India, and host the 1st National Conference on HIM INDIA INFO – 2015 on 4th & 5th Dec 2015 at Krishna Institute of Medical Sciences Ltd, # 1- 8 – 31/1 Minister Road, Hyderabad.

Very interesting to note that the participants across the nation and overseas including renowned speakers with vast experience in HIM, IT and allied fields from USA, Japan, Kuwait, UAE, Oman, Qatar and other nations and presenting more than 30 scientific /technical innovative practical topics on HIM, IT and allied fields and discussions on issues of current and future role of HIM profession in providing quality healthcare delivery system of the nation.

This Conference provides a platform for HIM & IT Professionals, Doctors, Nurses, allied health care professionals to interact with each other on a wide spectrum of topics related to Health Information Management. With the introduction of IT in Health Care Industry, it is necessary to discuss its implications in the Management of Medical Records, and its optimum utilization to enhance our efficiency and accuracy. I convey my best wishes to all the participants

Dr. B. Bhaskar Rao



10

Gullapalli N Rao, MDChairman

Health information is a critical component of effective, high quality health care. Documentation of all information, medical record systems and system to analyse that information for better management are all ingredients of modern health care facilities.

The increasing popularity of “Electronic Medical Records (EMR)” is a welcome development. While the initiation into this may appear traumatic, once established, these systems offer global flexibility in the subsequent utilisation of that data for better care.

I am delighted that Hyderabad is having the first Health Information Management Conference in India. I wish the conference all success.

GuLLAPALLI N. RAO



11

Sharing Personal Experience to Him From united Kingdom

Selvakumar Ramalingam, ACC(UK), AHRIM (UK), BMRSc, MA, MS, PGDHMTeam Leader, Clinical Coding, University College of London Hospital and Moorfields Ophthalmology Hospital, NHS Foundation Trust, London, UK.

Introduction

I would like to personally convey my sincere thanks to Dr. G.D. Mogli, Ph.D, FAHIMA (USA), FHRIM (UK) who is a Father of Medical Record of Gulf and India. First, I thought I wanted to send an article on Clinical Coding Health Information Management. I have seen this mail recently due to my personal commitment, earlier I couldn’t see this mail due to my hectic work commitment in other site.

Secondly, whatever topic, I want to write article that is already published by Dr. G.D. Mogli and he never left any topic for us. I know personally past 20 years and he is a “Legend” in this field. Instead of writing article, why don’t I may write about Dr. G.D. Mogli’s advice and guidance helped me to elevate this position would be more appropriate. Hence, I am sending this message from United Kingdom to benefit of our young Healthcare Professionals.

I would like to request all the young healthcare professionals should follow the below mentioned advises which has already given by Dr. G. D. Mogli and I sincerely followed and still following the same and I am getting every day the benefit of growing in my career. I am proudly say that my two children studying medicine in the United Kingdom.

The following are Dr. G. D. Mogli’s quote as an advice:

To acquire specialized skills in your Health Information filed wherever it is available.

To have through knowledge about Health Information, about update development and this is an ongoing process.

To have excellent professional skills in Health Information Management which include Policies and Procedures, Anatomy, Physiology, Medical Terminology, and other Para-clinical subjects knowledge.

To possess very good Leadership skills, this is very mandatory in our field.

To know how to act politely but diplomatically and tactfully, and express very authoritatively your views with other professionals.

To manage the department with minimum resource with high quality is mandatory requirement for any organisation.

To know how to start the system without resources such as men and other equipment’s and the same system will take care of you and your department if you show real good output.

To be a very good, loyal and truthful person to everybody and be an optimistic not a pessimistic and opportunist put you down in front of others. This is what happened most of the time.

Last 3 decades, I am in this Health Information field and I have visited more than 200 international reputed hospitals in UK, France, Germany, Italy, Saudi Arabia, Sultanate of Oman and India. I would like to share my view in this regard only on two aspects.

First, I would like to convey there are two ways of handling Hospital Health Information Managed as they are.

Integrated Health Record &Information management which means Health Records & Information Management run by Health Record and Information professional which include Accident & Emergency, Outpatient with Appointment, Inpatient with Admission Office, Waiting List Management, and Health Records & Information department functions are Collection of Health Records from Wards, Analysing the Health Records to identify the deficiencies and rectified the same, all the discharged patient need to be coded as per ICD and Procedure classifications, Filing the health record and compiling statistics for the Management purposes. These are the



12

functions are still carried out in Saudi Arabia, Kuwait, Sultanate of Oman, Bahrain, and Qatar and JIPMER (India) hospitals with unified Health Record and Information system which introduced by Dr. G.D. Mogli, all these hospitals - Unique Health Record & Information Policies Procedures which unbelievable and only one person has done this and I think, first and lost on this aspects.

Disintegrated Health Record & Information System which means above mentioned all the Health Record & Information functions are carried out by different departments and not under one head and also each department has Policies and Procedures which will lead into waste of time, money and manpower. This system only practices in UK and other countries.

I am wondering how this was possible to have National wide Unified Health Record System is still dream for many developed countries. So far I never seen, one integrated Health Record & Information system hospital in UK, France and India. The reason behind this Dr. G.D. Mogli one who brought this and I never find any one book equivalent to Managing Hospital Health Record & Information book with step by step policies and procedures can be followed any layman with minimum training.

I would like to request the entire Health Record & Information professionals should get Dr. Mogli’s published books and articles contain all valuable with practical live examples to run the Hospital Health Record & Management System in any organization. I am sure this policies and procedures will be followed for another century without any solidification. Even developed countries not followed 50% per of these policies and procedures.

I sincere regret for my inability to participate in this great congress, however, I seize this opportunity and send my best wishes for the grand success of the HIMA INDIA 1st National Conference to be held on 4th-5th of December, 2015 in Hyderabad, India.



13

Greetings to my coeval HIM Professionals

Vikky (N. D. Vikram)MBA., DMRS., BMRSc., CHRIM., QMS Lead Auditor (IRCA)., PRINCE2., ITIL.,Delivery Management Senior Advisor ERM / ESM / Revenue CycleDell Services | Global Healthcare ConsultingAddress: Dell FZ-LLC, Al Fardan Tower, Office Suite 846, 8th Floor,PO Box 31316, Doha, QatarTel: +974 [email protected]/healthcareconsulting

After my graduation in nineties, my uncle Late Mr. Luther inculcated into me a keen interest in HIM. Inspired by his enthusing over HIM, soon afterwards, I graduated from CMCH in BMRSc. Later, I did MBA in Hospital Administration and the following: Diploma as Med Record Specialist (USA), Certificated Health Record Information and Mngt (UK), QMS L.A. (UK), PRINCE2 (UK), ITIL (USA), JCIA (USA).

I worked in CMC Hospital (Asst. MRO), Ministry of Health – Sultanate of Oman (Asst MRO), Emirates group of Hospitals – Dubai UAE (MRO), Health Authority of Abu Dhabi UAE – (Sr. MRO, Clinical Informatics Consultant, Healthcare IT Projects Manager). I am currently working in DELL Global Healthcare Services in Qatar for HMC project as Senior Healthcare IT Consultant and Healthcare Revenue Cycle Project Lead.

I owe my growth to the upbringing my parents Mrs. Kamal Saroja and Prof. Richard had given me. I also thank my Engineer wife Raga Sudha who stood by me through thick and thin.

The origin of my healthcare career in no less an Institution than CMCH augured well as it attained rapid growth under the tutelage of no less a person than Dr. G. D. Mogli, my benevolent mentor and enlightened preceptor, who ruled the roost in Middle East while his phosphorescent brilliance dazzled many into discipleship around the world.

As Chief of HIMA Organization, my professional godfather laid firm foundation to many HIM professionals including me in HIM policies, work flows, standards, functions, ethics, EMR, etc. As a pillar subject in healthcare HIM is much too unwieldy to be put in a nutshell. Suffice it for me to avow that Healthcare shall last as my passion and pulse until my last breath.

I pray God to fortify my godfather as he is girding his loins to organize the Conference elegantly and meticulously for which he shall win laurels for the nth time in his lifetime.

‘One thing is for sure that HIM is the spinal cord of the Healthcare that dictates, supports and makes sure of quality healthcare delivery. And we all as qualified HIM professionals are privileged to feel proud who can vertebrae the EMR infrastructure of the modern healthcare world’.



14

Mr. M. Subhakar, DHIA, PGDHM, PGDMLS, SQC, SSG

Organizing SecretaryManager - HIM, Apollo Hospitals, Jubilee Hills, Hyderabad

I deem it my fortune and privilege to be in a position to welcome all speakers, delegates, students and members of the HIM fraternity this prestigious 1st National Conference, HIMA INDIA INFO - 2015. This is a prominent milestone for Health Information Management professionals and we, the HIMA India, are proud to organize this conference in December 2015 at Hyderabad. We are certain that you will enjoy all the planned programme, and we look forward to meet you during the conference.

I fully acknowledge that the health information management plays an important role in health care management and the quality of life of theindividual. Towards this end HIM professionals need to keep themselves constantly updated and their skills continually upgraded, and the HIM INDIA INFO – 2015 is a major opening for professional development. The scientific program of the event will reflect the evolution of our specialty, including state-of-the-art presentations on various hot topics adding with international flavor.

I desire and assure HIMA India events will always been a great venue for genuine exchange of experience and knowledge in a relaxed and convivial setting. We will continue these educational programmes through the year and years too. We now have the privilege to organize this auspicious conference under the guidance of Dr. G D mogli, “Father of Medical Records” India.

On behalf of the Organizing Committee of HIM INDIA INFO – 2015, it is my pride and privilege to invite all HIM, IT and allied Professionals to join us in the 1st National Conference of HIMA India to be held in Hyderabad, the city of pearls known for its heritage and hospitality. I wish this conference brings together the HIM professionals of India, and is an excellent chance for building and network.

We look forward to welcoming you in the city of Hyderabad and assure you to make your stay pleasant and productive.

Mr. M. Subhakar

Organizing Secretary



15

Mr. Kishore BabuHIMA-TreasurerLVPEI-Administrator & Head eMRD

Healthcare information quality and safety required that the right information be available at the right time to support patient care and healthcare systems management and making decisions. Improving consensus on essential data content and documentation standards are a necessary prerequisite for high-quality data in the interconnected healthcare system of the future. Health Information management is experiencing a transition from traditional managing practices with paper to more efficient electronic and digital management. Continuous quality management of data standards and content is key to ensuring that information is usable and actionable. But the main gole is still to analyze, manage and utilize the information that is essential to patient care and making sure that information is accessible when required.

I am sure that participants will share their innovative ideas, experience and deliberations which in turn would contribute a lot to the future development of health information management systems at the conference through exchange of best practice, would pave way towards evolving more efficient systems of eMRD.

I wish the ‘HIM INDIA INFO-2015’ 1st National Conference a great success.

(KISHORE BABAu.B)LV Prasad Eye Institute (LVPEI) HYDERABAD



16

Objectives:Upon participation of the congress, the participant able to:

• Recognize the problems of health records management in Developing Countries

• Appreciate the need for forming national association for HIM

• Grasp the struggle and great efforts of HIM personnel in the past

• Know the important personalities who selflessly worked for HIM growth

• Understand the objectives of IFHIMA and its overall activities

• Identify the role of IFHIMA/ WHO in improving the health record in Developing Countries

• Recognize the challenges of Developing Countries in maintaining medical records

• Scrutinize the role of HIM national association in development of HIM field

• Comprehend the Action Plan of National Association and its priorities

• Appreciate the Government participation in the growth of HIM field

• Enumerate suggested remedies for improving the HIM field in the country

• Know the challenges of IFHIMA in advancement of global organizations

Abstract:Introduction: The purpose of this paper is to enlighten the fellow members of IFHIMA especially from Developing Countries, the dire need of health records / information management association at national level to improve healthcare delivery system-including primary, secondary and tertiary care at all levels of the nation. For which adequate professionals are required to manage the HIM

Strategic Role of National HIM Association of Developing Countries in 21st Century

Dr. G. D. MogliPh.D., MBA., FHRIM (UK), FAHIMA (USA)

Visiting Professor, Medical Informatics, MGM Sciences, Maharashtra, IndiaFormer World Health Organization [email protected] and www.drmogli.com

departments in the health institutions. Without which the health institutions have to function without HIM departments or with non-qualified persons. Despite commitment to their profession, if they work isolated, it would be difficult to standardize and integration of the health record information technology in the country. Action Plan: All the employees working for HIM should be made members of the association and ensure that all are involved in the educational and professional growth activities with the support of workshops, seminars and conferences at institute, regional, and national levels. Government participation: The next step is involving the Government in the activities of HIM national association, by communicating the progress made and seeking the support for further improvements. The HIM should contribute in the national healthcare delivery program including eHealth management. IFHIMA’s Role: is to increase member nations especially, the developing countries to ensure that the activities of the association reaches to as many nations as possible in order to bring greater unification and standardization for easy global link and ultimately to accomplish the association’s objectives. Suggested remedies: Most important suggestion is to establishment of a central HIM department in the Ministry of Health to be headed by a senior HIM professional to oversee the development of HIM programs in the county. Setting national eHealth record standards, policies and procedures, conducting educational and training programs to generate professionals and enhance the professional eHealth technology knowledge and skills with close partnership with IFHIMA.

I. Introduction: Need for forming a National Association for HIM field: The purpose of this paper is to enlighten the fellow members of IFHIMA especially from



17

Developing Countries (DC), that there is a dire need of health records / information management association at national level. This to be formed by the health record / information management personnel in order to improve healthcare delivery system including primary, secondary and tertiary care at all levels of the nation through improving heath records /information management. For which adequate professionals are needed to manage the HIM departments in the health institutions. Without which the health institutions especially, the hospitals have to function without HIM departments or with non-qualified persons. Despite, commitment to their profession, if they work isolated, it would be difficult to standardize and integration of the health record management system in the country, since this field is least recognized and scant respect for the professionals in most of the DC, this further validate for forming the national association.

Demand of HIM Professionals globally: There is a high demand for HIM professionals throughout the globe; especially in Developing Countries. The national professional members could take the advantage of the International Federation of Health Information Management Association (IFHIMA) in drafting the constitution for forming the national association and its various activities that could be made use for building the health record /information management system in the respective country. The author also briefly furnished the historical background and evolution of the field for the benefit of the members. The main objective of the association is to provide best possible healthcare to the sick and injured. To achieve that, a national association is one of the most needed tools for health record management workers; with they can contribute effectively to the growth of the profession.

II. Material and Methods: The historical background and evolution of health records and the IFHIMA’s objectives and various activities should help in drafting the roadmap for Strategic Role of National HIM Association of Developing Countries in 21st Century. The medical records and its profession have undergone tremendous transformation since it’s forming first national association in the US in 1928. The health records, as we witness today, had undergone transformation e.g., in early period, the patient records title used to be chits, notes, documents,

became records, then medical records, steadily health records, electronic medical records /health records and today, known as paperless-digital eHealth records with the utilization of latest information and communication technology to meet the needs of 21st century. The developed countries are striving to make best use of technology with their organized professional associations to meet the goals and objectives of the healthcare institutions to provide best care to sick and injured and minimize the morbidity and mortality rate with safe and healthy living.

It is high time, to form the national association with proper objectives in collaboration with all the health records and healthcare professional members focusing on standardizing the health record /information management system in the nation that would benefit one and all. Ultimately, the national association could participate in the regional, national, and international arena to benefit in the standardization, education, training and improving professional attitude, knowledge and skills that enable utilizing the network technology compatible with international standards to solve the terrific health issues of developing counties.

III. Historical background:In 1902 records were discussed for the first time at a convention of the American Hospital Association to bring improvement of records through organization and training of record librarians. Some of the problems that were brought out at that meeting were that there was no uniformity in methods, no single type of person in charge of records. In 1905 Dr. George Wilson, Portland, Oregon, read a paper entitled “A Clinical Chart for the Records of Patients in Small Hospitals” at the 56th annual meeting of the American Medical Association. In 1913 the American College of Surgeons was founded by Dr. Franklin H. Martin, with the objective to raise the standards of surgery for which sound standard of surgical training that require patient data on the training. It was felt that to elevate standards of surgery by a standardization of hospitals, important role played by records was recognized in hospital standardization. Steady improvement both in the quantity and quality of medical records began with the advent of hospital standardization. Gradually, conferences of round-table type were devoted exclusively to the subject of medical records.



18

Mrs. Grace Whiting Myers, Librarian emeritus of Massachusetts General Hospital was appointed to organize committees, direct the preparation of program, and plan exhibits for a day meeting at which medical records and problems concerned with their content, availability, and preservation were exclusively discussed during the meeting on Clinical Congress of American College of Surgeons in Boston for which the medical record workers of USA and Canada participated. At this meeting, on October 11, 1928, the Association of Record Librarians of North America was formed with the main objective: “To elevate the standards of clinical records in hospitals, dispensaries, and other distinctly medical institutions.” Mrs Myers was elected first president.

In 1934 Elsie Royle, elected to work in hospital administration and was appointed to a new hospital in Manchester, England. She was given the responsibility of improving the medical records system. Elsie Royle’s thirst for knowledge increased. She planned a visit to North America in 1940 , but due to second world war (1939-1945) it was not possible. Hence, she wanted to improve medical record services in the UK. With the help and interest of others, she formed an Association of Medical Record Officers (AMRO) in the United Kingdom in the year 1948. The first International Congress on Health Records was held in London in 1952. Among the most significant milestones and landmarks in the recent history of medical record science are:

1. American and British endeavors to standardize medical records through formal organization and accreditation processes.

2. Organization of national medical record associations, the USA (1928), Canada (1942), Great Britain (1948), Australia (1952) and India (1972) and so forth.

3. Founding of the International Federation of Medical Records in Stockholm, Sweden in 1968.

4. Worldwide associations of medical record personnel foster the development of international standards and facilitate uniform statistical comparisons of heath data and disease classification systems. The International Federation of Health Records Organization (IFHRO) was initially recognized by the World Health Organization in 1968 when the Federation was invited to participate in the first World Study Group on Hospital Records in Geneva, Switzerland in November 1969.

IV. Objectives of International Federations of Health Information Management Association (IFHIMA)The International Federation of Health Information Management Association (IFHIMA) was established in 1968 as a forum to bring together national organizations committed to improvement in the use of health records in their countries. The founding organizations recognized the need for an international organization to serve as a forum for the exchange of information relating to health records, health information management and information technology.

The purpose of IFHIMA is to:

• Promote the development and use of health records information management in all countries

• Advance the development and use of international health records/information management standards

• Provide for the exchange of information on health record/information management education requirements and training programs

• Provide opportunities for education and communication between persons working in the field of health records/information management in all countries

• Promote the use of technology and the electronic health records

• These aspirations are achieved through the collaboration, networking and sharing of experiences and resources of IFHIMA members/

• IFHIMA is a non-profit organization affiliated with the World Health Organization (WHO) as a non-governmental organization (NGO).

V. Role of IFHIMA / WHO in improving the medical record status in Developing Countries: Prior to seventh international congress, only few counties were members of the IFHIMA. After 7th International Congress which was held in Toronto, Canada, in the year 1976, the member countries especially developing countries felt the need to have a representation in the WHO headquarters, as the medical record field was supervised by statistical division as part of it, not as an independent, and in fact, the same situation was existed in almost all the developing nations and medical record name was foreign to many. At the same time, the IFHIMA was



19

affiliated with the World Health Organization (WHO) as a non-government organization (NGO) and this lead to creation of a post of Medical Records Officer by the WHO headquarters. During the period 1976 -1996, the WHO had contributed by sending WHO short term Medical Record Consultants to few developing countries. The IFHIMA also assisted in training programs and inviting candidates for the congress from developing countries and supplying a basic medical record manual as guidelines for organizing the medical record departments.

The purpose of IFHIMA is to promote HIM in all the countries including adopt international HIM standards, exchange informational HIM educational requirements and training programs and promote and implement effective technology e.g. electronic health records

VI. Challenges of Developing countries in maintaining medical records: There were no professional associations at state and national level and inadequate educational facilities had hindered professional progress. Financial constraints were further blocking the development of the profession. There was no separate cell in the ministry of the health which could act as an advisory service to the government. There were no written policies indicating the importance of having the MR Department in a hospital. Retention and preservation of medical record schedule was not present. There was no recommended staff pattern, basic requirements like space, equipment etc., maintenance of basic medical records and statistics. The majority of medical record departments either absorbed only on inpatient records, or only engaged on outpatient records and very few had both the system.

As regards to medical staff, those served in mission and teaching hospitals preferred to have comprehensive records and fully cooperated with the MRD, while, many were not interested in documenting and maintaining proper records. Obviously, the work load in the hospital was too much and with inadequate medical and nursing staff resulted in incomplete documentation, as doctors felt that caring and saving patient lives was more important than spending time on documentation which they considered as clerical. And also not having standardized medical record forms, missing of investigation reports and records made them less

interested in completion. At least some personnel were employed in hospitals or large health centers, but rural primary health centers and sub-centers were managed by health workers without any training or proper instruction in the field of record keeping and reporting. Hospitals believed more in keeping registers rather than individual patient records. e.g., for pregnant mothers, infants, pre-school children, school children, adult outpatient etc., the information was scattered and no integration of information.

VII. National Association Objectives:

The purpose of National Association is:

• To elevate the standards of health records in the healthcare institutions.

• To serve as a means of communication among health information management (HIM) personnel and to conduct seminars and conferences for the benefit of the medical institutions

• To standardize health record / information management system throughout the nation

• To assist the Government (Federal or state) and other health agencies to improve the administration in medical education, research and patient care.

• To promote the HIM professionals including the staff employed in HIM field

• To give opportunity to HIM personnel for attending seminars and conferences within the country or overseas conducted by similar associations.

• To donate or to receive to, or otherwise aid any institution or organization in or outside the country connected with HIM professionals

• To diffuse useful knowledge among HIM personnel though mass media, such as advertisements, documentary films, television etc.

• To do and cause to be done such lawful things as are in accordance with the spirit and principles of the objectives of the association

• To affiliate any state run medical record / health information / medical documentation associations and guide / monitor their proceedings. Or get affiliated to the international federation e.g., IFHIMA as an active member.



20

VIII. Action Plan for the National Association:

The Role of National Association should deal with the following strategy as a priority:

• Professional standards to maintain high class health records-manual or electronic

• Contribute in patient care, medical education, research and management

• Improve professional status qualitatively and quantitatively

• Initiate professional educational and training programs

Forming the National Association: At the outset to ensure that there is a national association for HIM field, once that is achieved, the association should collaborate and cooperate with all related personnel and departments to ensure the representation is given to all committed personnel, who can selflessly work for the cause of the association. If there is no national association, the information furnished in the historical background should inspire the professional leaders to bring all HIM field personnel on one stage to have deliberations and discussions to form association at national level with clear objectives. Make an Action Plan with scheduled program and the attaching the responsibilities. The most important aspect is to ensure that all the employees working for HIM department should be made a member of the association and ensures that all the employees are involved in the educational and professional growth activities with the support of workshops, seminars and conferences at institute, local, regional, and national levels. To form different committees at local and national level that will facilitate in contributing in standardization and improved quality of health records /information management system with the support of information technology.

Government participation: The next step would be involving the Government including Federal and State in the activities of HIM national association, by communicating the progress made and seeking the support for further improvements. The HIM attention should be improving the health institutional records and their efficient management to provide best possible healthcare. In order to do that, the need for enhancing the HIM professional’s standards and status is vital. This could be achieved by having the modern HIM educational and training centers in the country. The three Tier educational

program can be developed for operational level (Asst. Technician), supervisory level (Technician) and manager level (HI Manager). Gradually, the higher professional programs such as master’s and doctoral can be planned in collaboration with universities, and started late as the association progresses. Most important is dedication and commitment and good team work by all the members. The leading personnel should act as Coordinator to ensure the action plan is put into execution as per the schedule and try to accomplish the set goals.

Suggested remedies:

• Establish a central HIM department in the Ministry of Health to be headed by a senior

• HIM professional to oversee the development of HIM programs in the county

• Setting of national standards for medical records / health information management

• Improve the quality of HIM professionals and HIM numbers

• Initiating HIM educational and training programs to generate needed manpower

• Conduct workshops, seminars and conferences for the benefit of HIM and institutions.

• Develop HIM policies and procedures including, the budget, staff pattern etc.

• Participate and assist the government in improvement of healthcare delivery system

• Develop partnership with IFHIMA and similar associations to enhance the HIM status

• Strive to advance the eHealth technology to meet dynamic progress of medicine

IX. Conclusion: The problems of developing counties are inherited and depend upon many factors, including its political history, its religion, its legal system, economical soundness and language. Low educational standards and administrative structure in general are some of hindrances for rapid progress.

With the advent of technology, and communication system, the global nations have to be closure, hence, as many nations as possible, especially the developing countries which need great help should be members of the IFHIMA to avail the benefits it provides through international integrated work by designing, developing and conducting the educational programs for the benefit of member



21

countries. The causes are many for being member of IFHIMA. The priority would be if some senior committed leader professionals could serve nation by bringing together the professionals’ form national association, if not existed, and get affiliated with the IFHIMA.

X. Recommendations:It is high time to enhance the IFHIMA member countries, especially the developing countries on war footing to ensure that the efforts and endeavors of the association reaches to as many as nations possible in order to bring greater unification and standardization for easy global link and ultimately to accomplish the association’s objectives.

Challenge: IFHIMA need to achieve its overall objectives to be global organization! The following suggestions are made for consideration by IFHIMA for achieving its overall set objectives.

• The IFHMA President should visit the selected Developing Countries (DC) to meet the government to develop rapport for collaboration and coordination relating to HIM Field of the country.

• The WHO might facilitate the visit of IFHIMA President to different nations of DC.

• Strong Suggestion for opening of a HIM cell in the Ministry of Health with a senior competent HIM professional to oversee the country’s HIM system and for creating national standards, policies, and developing HIM, training programs to meet the nations needs at par with international standards

• Award Honorary Membership to all those with 30+ years of active participation and significant contribution to the IFHIMA and use their services as IFHIMA ambassador for elevating the HIM field and profession in the needy nations with close association with IFHIMA directors

• The IFHIMA in collaboration with the WHO, assist the needy nations by selecting IFHIMA Honorary Member professional/s to be made responsible to visit to all the potential nations, as determined by the IFHIMA executive to promote the objectives of the association by personal meetings, or participating in their conferences as an observer.

• IFHIMA to classify the continents and sub-continents and select countries for each

continent.

• And the Five IFHIMA Directors can be made responsible for respective continent/sub-continent

• IFHIMA to have a list of retired professionals who can voluntarily contribute (without taking any pay except other expenses; such as travel, boarding and lodging) in this endeavor to assist the nation concerned on behalf of IFHIMA.

• IFHIMA should create a special budget by raising funds to meet the expenses required for the travel, boarding and lodging for honorary experts whenever the job is assigned.

• Strengthening the activities of IFHIMA by setting up information centre and data bank to gather the problems in managing HIM system and address the issues in DC.

• Conduct periodic educational program such as workshops, seminars for professionals of DC to enhance their knowledge and skills in eHealth and electronic health records.



22

eyeSmart EMR – Doorstep to Boardroom

Dr. Anthony Vipin Das, FRCSConsultant Ophthalmologist

Head, Technology L V Prasad Eye Institute, Hyderabad, India

AbstractThe LV Prasad Eye Institute (LVPEI) for the past 28 years has served over 20 million people, over 50% of them entirely free of cost, irrespective of the complexity of care needed. The LVPEI care model, called the Eye Health Pyramid encompasses service delivery at 4 different levels ranging from tertiary care to primary care in the villages. EyeSmart is a revolutionary national and international award winning ophthalmic Electronic Medical Record (EMR) and Hospital Management System developed by an in-house team at L V Prasad Eye Institute, India. 5 years since, the EMR has facilitated 1.2 million consultations and we have embarked on a vision to connect the DOORSTEP to BOARDROOM seamlessly in the LVPEI Network. The power of analytics and machine learning of healthcare data is the next frontier to explore in India.

The LV Prasad Eye Institute (LVPEI) was established in 1986-87 at Hyderabad as a not-for-profit, non-government, public-spirited, comprehensive eye care institution. LVPEI operates out of 137 locations, 120 of them being primary eye care centers located in remote rural villages. For the past 28 years, it has served over 20 million people, over 50% of them entirely free of cost, irrespective of the complexity of care needed. The LVPEI care model, called the Eye Health Pyramid encompasses service delivery at 4 different levels ranging from tertiary care to primary care in the villages. In the Village Vision Complex (VCC), 10 Vision centers connect to a Secondary Center which then refers patients requiring further evaluation and management to the Tertiary Centers linked to them. All patient clinical data is maintained on PAPER and stored in the Medical Record Department. Problems in Data retrieval include geographical barriers, storage space; long hours spent in gathering research data. We have embarked on networking the entire eye health pyramid of LVPEI on digitized medical records through eyeSmart EMR. The goal is to enable electronic documentation for faster retrieval sans geographical barriers and research purposes, and to transform the entire network into a paperless eco-friendly environment.

eyeSmart is a revolutionary national and international award winning ophthalmic Electronic Medical Record (EMR) and Hospital Management System developed

in-house led by me at L V Prasad Eye Institute, India. We have used an EMR concept of totally integrating all functions of a hospital from a common point namely the patient. All functions, including clinical and administrative, are interlinked in a single EMR and HMS system and through a single patient record. We have made use of different flash tools, document viewers, etc., to intelligently assist our doctors in managing patient data at the convenience of a click anywhere, anytime. Doctors can access case sheets on mobile phones, and have appointment details 24/7/365. The application is enabled for various platforms like iPads, iPhones, Tablets. The EMR has now evolved into an effective educational tool for our students and fellows who train at the institute. Standard procedures, classifications, evidence based medicine protocols integrated into the system help to deliver more effective care and also aid in teaching. Today eyeSmart EMR enables a seamless connectivity in medical care between the Village Vision Centers and the higher Tertiary centers for delivering cutting edge eye care and has resulted in time saving and increased productivity. We have successfully integrated 53 centers including the village vision centers that connect to their secondary centers respectively. Our patients can now move anywhere in that belt without having to carry any medical records and all the medical information is readily accessible to clinicians.

Benefits of the system include -Cost Savings :• Manpower costs for Medical Record Department

• Paper printing/ Storage costs

• Man hours saved in preparing elaborate reports

• View reports and status of any center, anywhere, anytime!

Improving Patient Service :• Accurate, comprehensive medical reports at a

single click

• Digitized prescriptions for medicines and glasses

• Lesser waiting time for patients

• Online booking of appointments

• Personalized SMS alerts



23

• Enabling better efficiency in patient flow in centers

Employee Productivity :• Lesser time spent on written records (30% less

time)

• Faster processing of information of patient statistics (90% less time)

• Reports at a click (100% Time saved)

• LIVE patient status displayed dynamically to Administrators (100% Time)

• Faster entry of patient medical records

• Faster printing of prescriptions, refraction records (90% Time Saved)

• Assessment of employee specific functions (80% Time saved)

eyeSmart EMR is built with a single vision in mind. We want to ensure that our patients get the BEST delivery of eye-care. Knowledge about the disease and the previous history is very VITAL to the treating Ophthalmologist to take decisions. In the rural setting, the need for accurate documentation is lacking. Patients move between different healthcare givers and the records are lost or poorly maintained. Our vision is to establish a transparent, seamless, effective EMR system in the rural areas that will empower both the patients and the physicians treating them.

Every single patient seen at our Village Vision Center gets an A4 size Medical Report printed immediately at the end of every examination. This enhances the Trust between the patient and the healthcare provider. This ensures a transparent platform to document all the clinical findings accurately. More importantly, we have seamless connectivity across the centers to view the examination details anywhere in the Network. We are exploring big data analytics and machine learning. We are in the process of expanding the system to all the 137 locations, 120 of them located in the rural Villages (Vision Centers) and Towns (Secondary Centers). We are committed to a transparent, efficient and cutting edge technology to ensure that we deliver the best services to our patients at all levels of the LVPEI Eye Health Pyramid spanning from the Tertiary Centers to the Rural Villages. Once, we successfully complete the installation of the remaining centers in the Network, we propose to showcase this as a model for all the other healthcare departments to implement as the workflow is very similar in the delivery of healthcare. This project has tackled the implementation of eyeSmart EMR at all the following levels successfully –

• Tertiary Center-

• City Center –

• Secondary Center-

• Village Vision Center



24

Introduction: Kuwait is the gateway to the Arabian Peninsula, It is bounded in the east by the Arabian Gulf, in the south-west by the Kingdom of Saudi Arabia and in the north and west by the Republic of Iraq, Modem Kuwait is identified with oil, and has a total population of 3,695, 316; out of this nationals 1,403, 962, (33%) and immigrants accounting 67% (2013) a total area of 17, 818 Sq. km., with Kuwait Gross Domestic Product (GDP); 175.8 billions USD (2013)

The Public Authority for Applied Education and Training (PAAET) is an academic institute in Kuwait; it is considered one of the largest institutes in the Middle East in terms of the number of enrolled students, The PAAET offers a wide variety of programs across its different colleges and training institutes. It was established on December 28, 1982, by law number (63) with the objective of developing and upgrading manpower to meet the challenge of shortfall in technical manpower created by industrial and economic development of the country.

The foundation of applied education and training was laid along with the initiation of oil exploration, production and export in Kuwait. In the 1950s, the State began to establish training centers and organized programs to prepare the manpower needed for the oil industry. After building the fundamental structure of the education system, the Ministry of Education established a number of specialized institutions to meet the increasing demand for skilled manpower. The other ministries established their own training centers and institutes as well. The State found it essential to establish a central body to supervise and coordinate the activities of these numerous institutes with the main objective is to develop the national technical manpower to meet the human resource needs of the country through its two sectors; Education and Training, The College of health sciences is the part of the public authority for applied education and training.

Medical Records Diploma Education Program in Kuwait

Dr. Saadoun Faris AlAzmi, MS, PhD ( USA )Associate Professor,

College of Health Sciences,The Public Authority for applied Education and Training, Kuwait.

Medical records programThe College of Health Sciences previously (The Kuwait Institute of Health Sciences), was started the medical record program 1985, the two year diploma program was developed by Dr. Mogli and other committee members and was started by Dr. G. D. Mogli, who was working as Medical Records Advisor to the Ministry of Health. The public authority had requested his services from the ministry of health to teach the two years diploma program in medical records. The same program is being run till now. The program consists of 68 credits which can be shown as follows:

The Medical records technician program courses

1st course:

Code and course

No.Subject Credit

No. of hours

weekly

EL . IIIEnglish for medical technician

5 10

MED 120 Medical Terminology

3 3

MED 156Anatomy and physiology

3 3

M. R 103Introduction to medical record field

2 2

M. R 104Health care delivery system

2 2

LiB 104Research and library

1 2

16 22



25

2nd course

Code and course No. Subject Credit No. of hours weekly

EL . 161 English for medical technician 2 4

MED 160 Clinical medicine 4 4

pharm 156 Pharmacology 1 1

M. R 105 Filing systems 5 12

Typ155 English typing 2 4

Elective Course* 2 2

16 27*Elective courses (Select any one)

Introduction to psychology - 114Human relations - 123 Kuwait History

3rd course

Code and course No. Subject Credit No. of hours weekly

EL . 211 English for medical record technician 2 4

MED 204 Content and analysis of medical record 4 8

MED 205 Coding and indexing 4 9

M. R 107 Introduction to statistic 4 6

Comp. 108 Introduction to computer 3 4

17 31

4th course

Code and Course No. Subject Credit No. of hours weekly

R 206 Managing medical record 5 12

M.R 207 Health information system 4 8

M.R 208 Computer application for medical record 3 4

I.E 101 Islamic education 2 2

TYP 155 Arabic typing 2 4

16 30



26

Summer practicum

Code and course No Credit No. of hoursweekly

M. R 209 3 30

The period of study of this program is two years (4 semester courses) and summer practical (6 weeks). The above courses consist of theoretical lectures and laboratory and clinical practice at hospital setting in the ministry of health.

All courses taught in English languages except elective courses taught in Arabic. The program starts from September to January and second from February to June and summer practicum starts from June to August.

Admission to the program: • Passed general secondary education with

minimum 55 %

• Passed an interview.

The Number of admission to the program is 30 candidates per course admitted both girls and boys. Graduate student will receive Diploma in health science (medical records). Student after finishing program will work at the ministry of health hospitals as medical records technician.

Conclusion:The syllabus curriculum, content and the teaching program developed since 1985 has been used for many years (till now), Due to advent of technology

and also the transformation of medical records into health information management. I had personally consulted Dr. G. D. Mogli and other professionals in order to develop the medical record program to be consistent with recent development and with special emphasis on technology as most of the health institutions are converting the manual paper record into electronic records. It became necessary to teach such subjects which will help medical records students for the career build-up.

Now, the two years diploma program of medical records at the college of health sciences is being reviewed for development under the direct supervision of qualified professionals with a mission that new developed program should provide instructions and clinical experience to assist students in developing the technical skills necessary to maintain components of health information system consistent with the medical administrative, Ethical, legal accreditation and regulatory requirement of health care delivery system of the ministry of health and consistent with recent developed program and with other university around the world.

Acknowledgement:I thank the officials of the College of Health Sciences and the public authorities for applied education and training, Kuwait, for their encouragement and support. My gratitude to Dr. G. D. Mogli, the Organizing Chairman and other members of HIM INDIA INFO-2015 for inviting me to participate and present paper in this great congress.



27

Health Information Management’s Professional Role in Efficient Management of Health Information in uSA

Dr. Jayachand PallekondaB.Com. LL.M., Ph.D., RHIM (USA)

Retired Health Information Manager (USA)

Introduction:Health information management (HIM) is the practice of acquiring, analyzing, and protecting traditional and digital medical information vital to providing quality patient care. HIM professionals are highly trained in the latest information management technology applications and understand the workflow in any healthcare provider organization from large hospital systems to the private physician practice. They are vital to the daily operations management of health information and electronic health records. They are responsible to health insurers, state and federal government and other regulatory agencies.

HIM work multi-settings:Health information management professionals work in a variety of different settings and job titles. HIM professionals do not just work in hospitals. They work for accounting firms, insurance companies, information systems vendors, government agencies, pharmaceutical research companies and others. They often serve in bridge roles such as connecting clinical, operational and administrative functions. These professionals affect the quality of patient care at every touch point in the health care delivery cycle. Having skilled HIM professionals on staff ensures an organization has the right information on hand when and where it is needed while maintaining the highest standards of data integrity, confidentiality and security.

HIM is an Expert: Him professional is an expert who possesses comprehensive knowledge of medical, administrative, ethical and legal requirements related to healthcare delivery and privacy of protected patient information. Manages people and operational units like Release of Information, File Room, Transcription Coding and Billing etc., Participates administrative committees and prepares budgets. HIM interacts with all levels

of an organization such as clinical, financial, and administrative and information systems.

HIM’s challenges:Ensuring the privacy, security and confidentiality of personal healthcare information has been a fundamental principle for the Health Information Management (HIM). Today HIM professionals continue to face the challenge of maintaining the privacy and security of patient information becomes more and more distributed in electronic systems. The challenge of this responsibility has been increased due to the constantly changing legislative and regulatory environment.

Regulations which have impacted privacy and security:1. The Health Insurance Portability and

Accountability Act of 1996(HIPPA)

2. The American Recovery and Reinvestment Act of 2009 (ARRA)

3. Modifications to the HIPPA Privacy, security and Enforcement Rules the Health Information Technology for Economic and Clinical Health Act; Final Rule.

HIM professionals use their expertise to protect health information and ensure the right information is available to the right people at the right time.

While operations still demand continued focus on day-to-day activities like EHR implementation, coding, revenue cycle, privacy and security and Release of Information (RIO) to name a few Health Information Exchange (HIE) and emerging technologies and payment reform initiatives are rapidly changing how healthcare documentation will be.

Health Information Technology (HIT):Health information technology refers to the framework used to manage health information



28

and the exchange of health information in a digital format. Professionals who work in Health Information Technology (HIT) are focused on the technical side of managing health information, working with software and hardware used to manage and store patient data. HIT professionals are usually from Information Technology backgrounds, and provide support for electronic health records and other systems HIM professionals use to secure health information.

Health Informatics (HI): is a science that defines how health information is technically captured, transmitted and utilized. Health Informatics focuses on information systems, informatics principles and information technology as it is applied to the continuum of healthcare delivery. It is an integrated discipline with specialty domains that include management science, management engineering principles, healthcare delivery and public health, patient safety, information science and computer technology. Health Informatics programs demonstrate uniqueness by offering varied options for practice or research focus.

Health Information Management (HIM) roles are evolving as the industry moves forward with a variety of initiatives, including implementation of an electronic health records. As the health record evolves into a complete and accurate picture of the patient’s treatment, including information from personal health records and health information exchange the need for advanced information management skills are needed.

HIM professional skill set: Organizations depend on HIM professional skill set. The convergence of clinical, documentation and coding processes is vital to a healthy revenue cycle, and more importantly to a healthy patient. To that end, Clinical Documentation Improvement (CDI) has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date.

A CDI program includes a myriad of people processes, and technology that must work together to ensure success. Organizations need a well rounded individual who can articulate effectively all of the pieces, documentation requirements, code assignment, coding guidelines and quality reporting.

In response to this changing environment, CDI Specialist must improve work processes, communicate with clinical providers and redesign clinical documentation improvement practices. CDI specialist must continue to learn and develop new skills and move forward with regulatory changes.

HIM professionals hold diverse roles within the revenue cycle for their organizations and physician practices such as CDI Specialists, CDI Managers, Coding Professionals and Revenue Cycle Auditors.

As a retired Department of Veterans Affairs Medical Center, Health Information Manager, I would like to mention that, over 8 million Veterans are currently (ex-servicemen) with Healthcare Administration, 153 active Veterans Administration Hospitals and 773 Community Based Out-patient Clinics (CBOCs).

Veterans Healthcare Administration (VHA) is the largest integrated Healthcare System in the United States of America. The VHA has generated a number of accolades in the recent past from outside healthcare systems and HMOs and has received rave reviews from the national press as well as VA providers, Administrators and staff. MY HEALTH VET is computer systems where a veteran can see her/his own medical records.

One most important and particular contribution to the Veterans Administration commitment to excellence in the healthcare field is its award winning CPRS (Computerized Patient Record System). The CPRS interface has proven to be an efficient model; many non-VA healthcare systems around the country and abroad have adopted the Veterans Administration’s lead in complete incorporation of a patient’s records with in a singular data base. For example if a veteran has had treatment at the Chicago Veterans Administration Medical Center, he/she can get treatment at Long Beach, California Veterans Administration Medical Center and their healthcare provider at Long Beach, California will be able to see the patient’s entire treatment records from Chicago VAMC or another VAMC. The Veterans Health Administration has embraced these technologies, thus eliminating the need for patients to retrieve copies of their healthcare records from other VAMC professionals. CPRS really was a godsend to providers who remember the paper- only record days. Now, there is no such thing as a “lost record”. Another added benefit of converting to all electronic



29

records has been the amount of paper that is saved each year.

Policy Statement: Patients receiving continuing care in the acute and ambulatory setting are required to have a Problem List as part of the Medical Record. The problem list is intended to promote continuity of care over time and among providers for the patient.

Purpose: The purpose of this policy is to provide guidance on initiating the problem list. When used properly and consistently, the problem list serves as a valuable tool in patient care management. The problem list and compiles all past and current patient problems, including social, psychological and medical problems in one location. At one glance, providers can determine which problems are active are resolved and formulate treatment plans accordingly. Additionally the problem list serves as a communication tool and aides in the evaluation and treatment decision when the patient is referred to a specialty physician for care.

Procedure:1. All clinic patients will have a problem list

initiated and maintained by the third visit. For inpatients treated for chronic or critical conditions, problems are entered into the problem list upon discharge.

2. All providers should review the problem list, add problems, and enter updates as appropriate.

3. Primary care providers have ultimate responsibility for maintaining an accurate problem list.

4. To maintain usefulness of the problem list, problems will be entered in a timely manner

5. Only approved staff will enter problems. Medical Directors will identify approved staff with in their clinic/department.

6. All problems will be listed as active until a licensed independent practitioner changes the problem to “resolved”.

7. If copy/paste functionality is utilized, the entry must be edited to ensure documentation integrity.

8. Problems will include:

• Items from organization –defined national standards

• Known significant medical diagnoses and conditions

• Known significant operative and invasive procedures affecting current health

• Known adverse and allergic reactions 9. All entries, when possible will utilize a standard

vocabulary to ensure classification of data for rules, alerts, and potential reporting. HIM professionals and clinic users will determine whether a classification or vocabulary system should be used for the entries on the problem list.

10. Only providers will be allowed to enter or edit designated problems or diagnoses onto the patient problem list, this is not within the role or scope of coding or coding audit professionals.

11. Development of system level problem folders requires approval by the HIM committee.

12. Abbreviations will be avoided in the problem list to ensure clear communication among all disciplines.

13. The HIM committee must approve all rules, alerts and system-generated problems at least one month before implementation. System-generated problems will be updated with resolved status by the requesting provider groups.

14. The problem list is considered a permanent part of the medical record and is included in the designated record set.

Summary:Efficient management of health information is not that simple, it needs besides acquiring professional qualification e.g., RHIM etc. one has to and not limited to the following:

• Have good communication skills

• Build up good public relationship

• Pursue continue education in the field by participating in the seminars, workshops, group discussions, and conferences national and international.

• Undertake specialized courses related to HIM to be proficient in the field

• Be a good leader with team building ability and other positive characteristics

• With this few tips, any HIM professional can achieve as adage goes “Sky is the limit” *



30

ConclusionWhen I mentioned; sky is the limit, I remember, a live case, amongst us here.

I convey my gratitude for inviting me to this great conference. I consider an honor and privilege in saying few words about Dr. Mogli, the Organizing Chairman of this conference. I have been associated with him for the last five decades since 1963 onwards. He is a live case to mention and proved that *“Sky is not the limit but beyond that; you may not know about him much, He possess along with a bachelor degree, 3 Masters, 3 Postgraduate diplomas and innumerable certificates, and First Doctorate in HIM field, and two prestigious Fellowships from United Kingdom and United States. He is the only Fellow of American Health Information Management Association (FAHIMA) in the entire word except some US citizens have this honor. He received from AHIMA as one of 2004 Triumph Award nominees for Honoring Those Who Make a Difference. He published more than 12 books (one from USA) related to HIM, and more than

105 articles in the international journals of repute. He has been participating in the international congress held all over the world since 1976. I had the chance to join in the conference in Netherlands (1980), New Zealand (1984), (During this conference, he was requested to be nominee for President /Secretary of IFHRO, he declined stating that he was in Kuwait and not holding any professional position), Dallas, USA (1988) and Washington, USA (2004). He conducted workshops, delivered guest lecturers in many countries. He was king and father of HIM field in nine nations as holding top position as Sr. Consultant Adviser to the Ministries. He was also World Health Organization Consultant which is a great honor for our profession. He is acquainted with nine languages including Diploma in French & Arabic Languages. I feel he is the only one who enjoyed good and bad of the HIM thoroughly. Dr. Mogli holds high regard and is well known among all IFHIMA member nations and in USA for his contribution to the profession.



31

Innovation in Medical Records Department

- Jhansi Jampanaa, Kaleshb, Rajeev Choureyc, Prabhad, Preeti Patele

Introduction: Documentation acts as an evidence for the tasks performed and for the activities to be performed. Hence it serves as an important communication link between different individuals involved in the same process for completion of task. Therefore it is aptly said:

“If it is not documented, it was not done”.1

Documentation plays a very vital role in hospitals, especially because it deals with human life and is also considered as a matrix organisation.2 In other terms, during an average stay of 3-4 days of a patient in hospital, care is delivered by multiple care providers including doctors, nursing and technical staff etc. Due to involvement of multiple people in this task it is considered to be complex and also error prone. Hence, documentation is important for ensuring effective and efficient care delivery and continuity of care.

The record related to care delivery process of patient is called medical record. This includes details such as: history and physical assessment, present complaints, provisional diagnosis, treatment plan including regular reassessments, investigations performed, medications administered, and details of any procedure performed and discharge summary etc.3, 4

These records are handled and maintained by Medical records department (MRD). Few important activities performed by/ functions of MRD are: keeping an up to date record of admissions, discharges and respective patient medical records, tracking and retrieval of records, maintaining statistics of all types, timely submission/ updation of mandatory reports to government authorities, handling queries of all stakeholders related to above processes, issue of records on request etc.5 In other words, effectiveness and efficiency of medical records department can be assessed by proper medical records management.

It is perceived that Electronic Medical Records (EMR) is the most preferred system for medical records

management as it helps in improving efficiency by eliminating waste in the process. Electronic medical record refers to systemized collection of patient and population electronically stored health information in a digital format6. The contents of the record are customized based on organization/ need or requirement of the user. Implementation of this system is time consuming & requires large amount of investment.

Medical records team in our hospital was facing difficulty in tracking as well as retrieval of records due to:

• Receipt of records from multiple areas/ departments (mostly timelines for submission are not met).

• The system being completely manual.

This was a time consuming exercise in turn impacting other activities to be performed by the department i.e. efficiency of departmental functionality was getting effected.

Method: Multiple levels of discussions with in the department i.e. with frontline staff and with different stakeholders were conducted. Visits to MRD across few hospitals were performed to understand process of functioning of those departments. The purpose of all these activities was to find the best possible solution which is easily implementable at the earliest. After all this, team decided to use MS Access for data management related to multiple processes since implementation of EMR is still under consideration. The purpose for considering this solution was that it requires minimal additional resources, requires less time for implementation and seems to have a significant impact on overall functioning of the department.

MS Access is a database management system that combines functionality of a database and the programming capabilities to create end user screens.7

Data capturing template has been designed as per



32

the requirements in MS Access & is being revised regularly based on inputs from the users. Every shelf has been labeled with a rack number and provision has been made in the program to assign a rack number to every record. This initiative has eliminated registers in MRD.

Innovation is a process of translating an idea or invention into a good or service which creates value for its stakeholders. To be called an innovation, an idea must be replicable at an economical cost and must satisfy a specific need. Innovation involves deliberate application of information, imagination and initiative in deriving greater or different values from available resources.8

Innovation has to be part of culture of the organization. During this process inputs from all stakeholders has to be taken specially front line workers of the process. People working on the ground will be aware of the frequent issues in the process and also its impact on the overall efficiency. Similarly these people can give the practical solutions which are easy to implement.

Overall, innovation is a part of continuous quality improvement. Accreditation system and competition have put emphasis on continuous quality improvement as it helps in making process more effective and efficient, and also supports reduction of waste of any kind.

Value addition from new system: 1. Tracking & retrieval of records: It takes less than

a minute to know the actual location & two-three minutes for retrieval of a medical record in Medical records department. Earlier this time was around 10-15 minutes. The records which are issued are also updated in the system at the same time. This has further improved traceability.

2. Pending records list generation: This list is automatically generated after the fixed time period to initiate follow up for the records not received. Earlier the document was being prepared manually from registers, there was every possibility of missing a record and staff will get to know about the same only when they start tracing the record for some purpose.

3. Statistics generation: Statistics related to births/ deaths, admissions discharges etc. can be generated within few seconds. Earlier this was an additional activity.

4. Handling additional query related to data: Staff is more comfortable and efficient in answering any query related to data for operational decision making. Periodical reviews which happen at different levels result in requirement for some additional data for decision making. For example data related to ALOS specialty& payer category wise, death rate of a specific specialty during a time period, post operative mortality, completeness of medical records related to NABH standard requirements etc. Earlier this data was being compiled manually which was a laborious and difficult task.

5. Cost effective, less time consuming way of data management: As evidenced from the above, the time for any type of data retrieval related to medical records has reduced considerably and hospital has not spent any additional cost for this initiative.

Conclusion: In order to ensure that the system remains dynamic and sustainable, it is important to continuously innovate. This innovation of using MS Access was from our medical records team. Our experience of this in house innovation during last few years has been very encouraging; it has improved the data management and eliminated most of the problems faced by the staff along with improving effectiveness of the system.

a, b: Medical records department

c, d, e: Medical Services (Quality)

References: 1. http://anderscpa.com/healthcare documentation/

2. Page no. 9-10, Role of Hospitals in Healthcare, Principles of Hospital Administration & Planning, BM Sakharkhar

3. h t t p : / / p o l i c y . u c o p . e d u / d o c / 1 1 0 0 1 6 8 /LegalMedicalRecord

4. https://en.wikipedia.org/wiki/Medical_record

5. Page no. 225, Medical records, Principles of Hospital Administration & Planning, BM Sakharkar

6. https://en.wikipedia.org/wiki/Electronic_health_record

7. http://www.techonthenet.com/access/

8. http://www.businessdictionary.com/definition/innovation.html



33

Introduction:EMR: Electronic Medical Record, it is a systematic, sequential and chronological ordered patient’s health information in electronic form, in a given time frame, in any healthcare centre. EMR systems are designed to store, retrieve, transfer, and share data safely, efficiently and accurately at low cost maintenances. EMR can improve the efficiency and quality of medical care and can minimize the repetition of work done.EMR will help in reducing a bit in Carbon Emission into atmosphere; consequently; will put affect on reducing Global Warming.

Aim:To introspection the progress achieved in Medical Record Departments, in developing and transforming, medical record documents into Digital/Computerized Form within AIIMS.

Methodology:Prepared desired questionnaire which contains 30 essential MRD documents related to patient care. The said questionnaire was floated among all MRD sections of AIIMS and collected information. Questionnaire Prepared is as:

Name of Centre :_____________________________

Date of Data collection: ________________________

Name of Data collector :______________________

(Sign) _____________________________________

Title of study: EMR status in AIIMS

Total Bed Strength in centre: ____________________ OPD Data Total (2014-2015)

Total In-Patient Admission in centre: ______________Male +Female = Total Patient

To MROM.R. Department Kindly issue the following information to the bearer 1-30 questions:

Sl. No

M.R. Documents Patient Paper Record in

Electronic Form (Y) for

Yes(N) for

No1. Casualty Registration Slip2. Face Sheet3. Discharge Summary4. Death Summary5. OPD Card6. MLC Report7. Casualty Note8. Clinical Notes9. Nursing Chart10. Nursing Daily Record11. Patient Information

Aadhar Card link12. Investigation Report

13. Operation Record14. Consultation Record

15. Consent Form16. Anesthesia Record17. PET Scan Film

18. PET Scan Report

19. CT Scan Report20 USG Report

21. MRI Film

22. MRI Report

23. Pediatric Immunization Record

24. Drug Distribution Record25. In – patient Display Unit

26. Online Patient OP Registration

27 Histopathology Report28. Death Record

29. Birth Record30. PM Report

Electronic Medical Record

To study EMR Status in AIIMS

R. K. Kaul, Jr. MRO – JPNATCMedical Record Technicians –JPNATCDr. S.K.Bhoi (Faculty In-Charge MRS )



34

(Dr. S.K.Bhoi ) (R.K.Kaul) Principal Investigator Investigator

Statistical Methods, tool, tests and techniques are involved in this Sample study

• Various Statistical tool, tests of Significances and techniques are involved in this study: Sample questionnaire prepared, Census collection Method adopted, Bar-Chart, Pia-chart, Pearson’s K2 test, Simple Average, Percentage, Used Primary Data, various references and Help books used,... etc

• The work done/ initiated is indicated by symbol “Y” and work not done /not initiated is indicated as symbol “N”. The range of digitalization of documents is set as:

• ( Where Documents in digital Form)

• Y = /26 ~ 30 → Access through Internet application/s to AIIMS Medical record Documents

• Y= / 21 ~ 25 → Full Digitalization

• Y= /16 ~ 20 → Semi-Digitalization

• Y= /11 ~ 15 → Progress :Achieved

• Y= /06 ~ 10 → Progress :under Process

• Y= /01 ~ 05 → Initiated

• y= / ~ 00 → Not Initiated

Result: The Centre wise statistics is indicated below:

Sl.No

Super Speciality Centre No. of Documents in

Total No. of Doc.

%age of Digitization/

Computerization

Centre wise Result.

YES NO01 JPNATC 20 10 30 67% Semi-Digitalized02 AIIMS

(Main Hospital)18 12 30 60% Semi-Digitalized

03 IRCH 08 22 30 27% Progress: Under Process04 RPC 08 22 30 27% Progress: Under Process05 NSC* 05 25 30 17% Initiated06 CTC* 05 25 30 17% Initiated07 CDER* 01 29 30 03% Initiated08 NDDTC 01 29 30 03% Initiated09 CRHS 02 28 30 06% Initiated10 OUT-REACH OPD 02 28 30 06% Initiated

Over all AIIMS Performance

73 227 300 24% Progress: Under Process

*Data OPD Basis.

(Above Information is depicted with bar-chart tool)

%age of Medical Record Documents Centre-wise in

Digital Form i/r/t Whole AIIMS

(PIE CHART tool)

Sl.

No

Super Speciality Centre

%age of Medical Record Documents Centre-wise in Digital Form i/r/t Whole AIIMS

01 JPNATC 24%02 AIIMS

(Main Hospital)21.60%

03 IRCH 09.60%04 RPC 09.60%05 NSC 06%06 CTC 06%07 CDER 01.20%08 NDDTC 01.20%09 CRHS 03.60%10 OUT-REACH OPD 02.40%



35

Results Cont./-• Medical record documents of patients need to be

computerized /digitalized for the safety, Security, future planning of treatment, research purposes, drug trial purpose and hospital expansion purposes, Hospital industry developing purposes, etc…

• It also becomes essential for every healthcare centre nowadays, to store data in Electronic Form, for hospital safety and patient health information purposes. It can be stored and retrieve at a very low cost maintenance.

• It can also reduce a bit Carbon Emission into atmosphere; consequently, will put affect on reducing Global Warming.

• DISCuSSION:

• During the course of study, it was seen that the information collected from MRD offices was bit difficult to collect. Because of the fact, such a survey was conducted First time in AIIMS by MRS

and the MRD staffs concerned feels reluctant to reply the questions asked by enumerator. Besides this fact, some Super speciality Centres did not provide information in time. Like NDDTC, OUT-REACH OPD, CRHS, CDER. They took too much time to reply, than rest of Centres, like JPNATC, NSC, CTC, RPC, IRCH and Hospital (Main) submit their respective reports in due course of time.

Conclusion:Many efforts had been taken by AIIMS authority in past, to digitalize medical record. It had proven good results; this study reflects that AIIMS had initiated the process of Digitalizing patient’s health information. At the same time, there are many areas, where the process of digitization is pending. Such areas have identified through this Study; and need to transform paper document into Digital Form for Hospital improvement and for smooth functioning and showing High level of patient care delivery system in AIIMS.



36

The health information management (HIM) profession is the heart of the health organization; with each beat it supplies much-needed health information to all users, such as physicians, staff nurses, allied health professionals, health administrations, insurance companies, the Ministry of Health and others. The main role of the HIM professional is to maintain organized and accurate data, and they need to accomplish numerous tasks in order to fulfill this goal. Health information professionals, therefore, need to integrate a variety of skills, such as expertise in computer and information technology (IT), a strong knowledge of medical terminology, disease processes and other conditions, experience of clinical classification systems and excellent managerial skills, to enable them to manage the range of health information services for which they are responsible, including human resources (Abdelhak, Grostick & Hanken, 2012; Green & Bowie, 2011). The HIM professional plays a critical role in completing, protecting and ensuring the availability of high-quality clinical information for purposes including patient care, reimbursement, quality assurance, research, statistics gathering and management decision making (Goedert, 2013; Safian, 2012).

Health information management was formerly known as “medical records administration” (Bennett, 2010; Goedert, 2013). The professionals involved were responsible for protecting patients’ legal medical records, which were in paper form (Goedert, 2013). However, the introduction of IT has had a huge influence in changing the responsibilities of HIM professionals. It makes the role more complicated and divergent due to the introduction of electronic health records (EHRs) and the necessity for them to be available to many healthcare providers and others such as insurance companies, researchers, court and for administration purposes simultaneously (Goedert, 2013; Watzlaf, Rudman, Hart-Hester & Ren, 2009). The integration of IT in

Health Information Management Professionals[Current Status and Future Prospects]

Raniya Humaid M. Al-Kiyumi, MHIM, BSc, GCert Ed. Studs., AHIMA & HIMAA Member

(A phD student in Australia)

the healthcare system has increase the need for HIMs who understand the use and meaning of the information that forms the health record, and the language used to describe the reality of clinical treatments and financial operations, and who can operate as central planners in many new enterprise initiatives. This means more employment pathways and opportunities have become available for HIM professionals (Goedert, 2013; Watzlaf et al., 2009).

However, many HIM professionals still believe that one of the greatest challenges facing them is having the ability to provide a simple answer to the question, “What is HIM?” in the current electronic world. A recent study pointed out that HIMs run the risk of their value being diluted in the eyes of other professional groups (Bennett, 2010). For instance, during discussions at the Technology in Healthcare summit in 2009, the absence of HIMs at the summit was noted, despite HIM professionals playing an important role in the implementation and use of EHRs (Bennett, 2010). It seems HIM is not considered a traditional hospital-based profession anymore, but also has “a non-traditional career path” (Jacob, 2013). Indeed, HIM professionals believe that unless they are able to clearly articulate what it is that they do and what it is that makes them unique, the profession will find it difficult to convince others of the importance of HIM in the future health sector workforce (Bennett, 2010; Street, 2012). Other studies state that in spite of the importance of HIM in protecting hospitals’ and patients’ clinical information, and in ensuring appropriate funding for hospitals, it is considered a hidden profession (Goedert, 2013; Safian, 2012; Shepheard, 2010). Moreover, HIM professionals are the ones who understand how information is used in healthcare institutions, and they play significant roles in managing, analyzing and protecting digital healthcare information; therefore, it is necessary for them to be visible at the forefront of the process (Jacob, 2013).



37

As such, there is a critical need to define the HIM profession accurately and to determine its key roles in the healthcare system. The overall aim of this paper is to discuss the contemporary challenges that the HIM profession faces and that influence its sustainability.

The main responsibility of the HIM profession lies in collecting, maintaining, analyzing and protecting patients’ clinical information in order to facilitate quality patient care. In addition, it is important to ensure that accurate health information is available to authorized people at the right time for different purposes while, at the same time, maintaining the privacy, security and confidentiality of a patient’s clinical information (AHIMA, n.d.; Baine & Kasangaki, 2014; Goedert, 2013; Jacob, 2013; Safian, 2012; Shepheard, 2010; Watson, 2008). With the development of EHRs, the roles and responsibilities of the HIM profession have become more crucial to safeguarding the confidentiality and security of patient clinical information (AHIMA, n.d.; Goedert, 2013). Despite its importance, there are many challenges influencing the sustainability of the HIM profession within the healthcare system. It is clear that most of the literature to date has tended to focus on the problems facing the HIM profession, rather than the solutions, and on the conflict of views in this area (Hurst & Kelley Patterson, 2014). Therefore, the future of HIM remains unclear, and it is important to gain more knowledge about, and a greater understanding of, the profession, with the aim of making a significant contribution to research in the HIM field.

The HIM profession takes responsibility for assessing the quality of health information in the health sector, particularly in hospitals. However, despite this important role, previous studies indicated that many people, particularly within the healthcare system, have only a vague idea about what HIM entails. The lack of understanding and appreciation of the profession has affected the status of HIM and the sustainability of the profession in the healthcare system. One of the most significant issues perceived from the literature is the inconsistency in the name or definition of HIM (Hurst & Kelley Patterson, 2014). It is referred to in some studies as “health information” and in others as “health information systems” or “information management”. The transformation of the professionals’ title, from being known as “medical record librarians” to “medical records

administrators” and currently to “health information managers”, based on the rapid development and changes in the nature of work (Bennett, 2010), may be the reason for this inconsistency. In addition, the different disciplines covered in the HIM study field, such as health science, leadership and management, law and finance and IT (Walton, 2012), have contributed to the misinterpretation of the nature of the profession. Therefore, an essential step for the profession is to attain a clear consensus on the scope of practice, roles, job titles, competencies and educational needs. Otherwise, it will remain difficult to promote the importance and uniqueness of the profession to others (Bennett, 2010).

The implementation of technology in healthcare has revolutionized HIM practice. Many studies have found that the availability of a well-trained and qualified workforce is an important factor affecting the implementation of EHR (Hersh & Wright, 2008; Hurst & Kelley Patterson, 2014). However, a conflict exists in determining the appropriate qualified staff member to ensure the success of EHR implementation. Is it the HIM professional, or is it an IT or other professional? Alternatively, is it the responsibility of different bodies, with different roles for each? Hersh and Wright (2008) attempted to determine the number of IT professionals required to ensure the effective implementation of EHR, while many other studies demonstrated the importance of the presence of HIM professionals in the success of EHR implementation (Dyson, Greene & Fraher, 2004; Hurst & Kelley Patterson, 2014). It is important to understand and clarify the meaning of success in EHR implementation, as it includes factors such as privacy and security issues, the provision of quality data and the provision of data that is fit for purpose. As demonstrated in the literature, there is no clear definition of health sector IT (Zeng, Reynolds & Sharp, 2009). Therefore, it is important, as stated by Hersh and Wright (2008), to determine which professionals play an important role in the implementation of EHR, and to clearly define their roles, in order to avoid any overlap in responsibilities. In addition, it is important to understand that there is a difference between what an information system can be expected to do, who manages it and how (Zeng et al., 2009).

“Workforce” is a widely used term in all arenas, and workforce planning has been seen as a major issue recently due to the workforce disparities that provide an obstacle to many organizations



38

achieving their objectives. Staff satisfaction and education, and staff retention, are jeopardized by poor workforce planning and development (Hurst & Kelley Patterson, 2014). The same is true in terms of the health workforce (Al-Sawai & Al-Shishtawy, 2015). In the UK, the Department of Health has defined workforce planning and development as “a dynamic process, where the right staff with the right skills is in the right place at the right time at the right price” (Hurst & Kelley Patterson, 2014). Similar to the discrepancy in many health professions’ workforce supply and demand, studies have attempted to quantify the need for HIM professionals in the changing process of collecting and processing health information (Safian, 2012; Sheridan & Smith, 2009). Other studies have noted a shortage in qualified HIM professionals; however, those studies failed to identify the extent of the shortage due to various challenges. These included the unavailability of a license or certification to work in the field, the number of the HIM workforce working based on a job training program and the cross-training or cross-practicing that exists in the workforce, where a staff member with a specific credential is doing more than one job, not necessarily based on their job title or job description (Dyson et al., 2004; Ledikwe et al., 2013).

It is known that a skilled HIM workforce is a critical component of a well-functioning healthcare system. Thus, many studies emphasized the need for changes to the future configuration of the HIM workforce to take on new roles and responsibilities and to highlight the importance of capacity development as a means of improving data quality (Hurst & Kelley Patterson, 2014; Ledikwe et al., 2013; Sheridan & Smith, 2009). Therefore, to provide high-quality data for decision making, either for patient care or management and planning, it is critical to be able to clearly determine the status of the HIM profession and develop a detailed plan for the health information workforce because, as Hurst and Kelley Patterson (2014) state, the relationship between staffing and service quality is irrefutable. It is also necessary to determine a means for entry into the HIM workforce, and to set clear criteria for recruitment into that workforce based on position descriptions, job titles and the qualifications required at each level (Dyson et al., 2004; Hurst & Kelley Patterson, 2014). Finally, it is important to construct an effective and efficient recruitment strategy that is aimed at encouraging

more people to become competent HIM professionals (Safian, 2012).

Education is a cornerstone in supplying the healthcare system with a qualified and trained workforce to provide a quality service and, specifically for the HIM profession, to provide high-quality data. In fact, the US Bureau of Labor Statistics showed that the HIM field is growing; medical records and health information technicians is one of the 20 fastest-growing occupations in the USA, with an expected growth of 22% between 2012 and 2022 (Bureau of Labor Statistics, 2014). In addition, according to an article by US News and World Report, HIM is now considered to be among the top developing study majors in the USA (AHIMA, 2012). Coordination between educational institutions and practicing professionals is crucial in ensuring that education meets the market demand. In addition, modification to Education and Training

Skilled Workforce Service Delivery Service Development and the creation of new materials for an HIM educational program should be based on stakeholders’ feedback (Al-Qahtani, Almansour, Alharbi, Aljasser & Alsunaid, 2013). However, several sources have identified that students are not attracted to enroll in HIM courses due the lack of recognition of the HIM profession and its unclear career path (Bennett, 2010; Dyson et al., 2004; Hurst & Kelley Patterson, 2014). Previous studies demonstrated the difficulty in tracking the numbers of HIM graduates due to the variation in the education of the HIM workforce, which has led to employers being unable to differentiate between the HIM qualifications and alignment with sets of work criteria (Dyson et al., 2004). Therefore, it is necessary to review and possibly revise the HIM competencies created by the American Health Information Management Association (AHIMA) and the Health Information Management Association of Australia (HIMAA) to ensure these meet current requirements in the workplace, and to inform future HIM educational developments based on service and workplace needs (Hurst & Kelley Patterson, 2014).

It is also necessary to consider the certification and credentialing of HIM professionals. However, HIM certification in many countries is considered optional, and can be carried out by different authorities (Dyson et al., 2004). Suzan et al. (2004) stated that having a single source of certification in each country



39

is important in eliminating misunderstandings about the profession, as the certification will clearly define the profession, job titles, competencies and educational requirements (Dyson et al., 2004). Therefore, it is necessary to determine the qualifications framework, the allocated job titles and the key competencies. It is also important to determine the certification body for those involved in HIM before they join the workforce. The figure below displays the relationship between education and training in providing a qualified workforce to an organization that must deliver a service. It also clarifies that service development influences the education and training sector; therefore, educators must be involved in supporting the workforce through in-service training and continuing education (Hurst & Kelley Patterson, 2014).

Source: WP&D cycle (Hurst & Kelley Patterson, 2014): Due to rapid developments in the HIM profession, both Jacob and Safian have indicated that the profession now offers a range of new career opportunities (Jacob, 2013; Safian, 2012). There are many new job titles and responsibilities for HIM professionals due to that development, and AHIMA has created a career map for the HIM profession (Sandefer, DeAlmeda, Dougherty, Mancilla & Marc, 2014). In addition, another study recommended creating a website focused on the job opportunities available within the HIM field as a means to motivate students to enroll in HIM programs (Safian, 2012). However, there are doubts about the applicability of the map and the efficacy of the website in different contexts. Therefore, there is a critical need to systematically address and solve those challenges first, and then move on to determining the new career opportunities based on consensus. Safian (2012) concluded that knowledge of the availability of new career opportunities would have a great influence on the enrolment in HIM programs and increase the importance of the HIM profession.

The questions for HIM strategic planning and workforce planning are: Which body is responsible for ensuring the effectiveness and efficiencies of both kinds of planning? Which body is responsible for following up these issues? (Shepheard, 2010). It has been demonstrated that health information managers are not always present at, or invited to attend, the decision-making tables that create policies and consider employment and contracts (Abrams & Crook, 2011; Goedert, 2013). This has

the potential to affect the sustainability of the HIM profession (Abrams & Crook, 2011; Shepheard, 2010). Previous studies have acknowledged generally that responsibility for ensuring the sustainability and availability of the HIM workforce lies with the government, educational and training institutions, healthcare institutions and HIM professionals themselves (Shepheard, 2010). However, it is important to determine clearly the bodies responsible for planning, and to specify the extent of their input, to ensure transparency when addressing the issues currently facing the HIM profession, such as those related to workforce demands and career opportunities. The recommendation from the workforce report is to form a strategic relationship by developing a single body to represent HIM (Hurst & Kelley Patterson, 2014; Shepheard, 2010).

In spite of the importance of HIM to the healthcare system in recent years, policy makers and leaders have paid scant attention to the role of HIM professionals. Thus, there is now a specific and crucial need to raise the recognition of the HIM profession by addressing all current challenges and making plans to cope with the ones to come. This will require all loyal HIM professionals to join hands in each of their contexts. In addition, HIM professionals must maintain their own strength and motivation, and that of their subordinates and peers, because as stated by HIM expert Professor Phyllis Watson, “Are we still strong to face the challenges and raise the status of the profession?” (Watson, 2008).

Acknowledgement I would like to thank Professor Fitzgerald (Principal Supervisor), Professor of Public Health in the School of Public Health and Social Work, Faculty of Health at QUT, and Director of CEDM, and Mrs Sue Walker (Associate Supervisor), a senior lecturer at QUT’s School of Public Health and Social Work, for their constructive comments on this paper.

References • Abdelhak, M., Grostick, S., & Hanken, M. A. (2012). Health

information: management of a strategic resource. St. Louis, MO: Elsevier Saunders.

• Abrams, K., & Crook, G. (2011). The Canadian Health Information Management Association: health information management in Canada: HIM-Interchange.

• AHIMA. (n.d.). New AHIMA Book Addresses PHRs - ADVANCE For Health ... (n.d.).

• Al-Qahtani, M. F., Almansour, R., Alharbi, A., Aljasser, M.,



40

& Alsunaid, H. (2013). Employer Perceptions of Workforce Preparation of the Graduates of the Health Information Management and Technology Program. Journal of American Science, 9(12).

• Al-Sawai, A., & Al-Shishtawy, M. M. (2015). Health Workforce Planning: An overview and suggested approach in Oman. Sultan Qaboos University medical journal, 15(1), e27.

• Baine, S. O., & Kasangaki, A. (2014). A scoping study on task shifting; the case of Uganda. BMC Health Services Research, 14, 184. doi: http://dx.doi.org/10.1186/1472-6963-14-184

• Bennett, V. (2010). Health Information Management Workforce - When Opportunities Abound. Health Information Management Journal, 39(3), 4-6.

• Dyson, S. L., Greene, S. B., & Fraher, E. P. (2004). A shortage of health information management professionals: how would we know? Journal of allied health, 33(3), 167-173.

• Goedert, J. (2013). HEALTH INFORMATION MANAGEMENT: WHAT A RIDE IT HAS BEEN. Health Data Management, 21(10), 22-24, 26-27.

• Green, M. A., & Bowie, M. J. (2011). Essentials of Health Information Management: Principles and Practices (Second Edition ed.). USA: Delmar CENGAGE Learning.

• Hersh, W., & Wright, A. (2008). What workforce is needed to implement the health information technology agenda? Analysis from the HIMSS Analytics™ database. Paper presented at the AMIA Annual Symposium Proceedings.

• Hurst, K., & Kelley Patterson, D. (2014). Health and social care workforce planning and development–an overview. International journal of health care quality assurance, 27(7), 562-572.

• Jacob, J. A. (2013). HIM’s evolving workforce. Preparing for the electronic age’s HIM profession shake-up. Journal of AHIMA / American Health Information Management Association, 84(8), 18-22.

• Ledikwe, J. H., Reason, L. L., Burnett, S. M., Busang, L., Bodika, S., Lebelonyane, R., . . . Mmelesi, M. (2013). Establishing a health information workforce: innovation for low-and middle-income countries. Hum Resour Health, 11(1), 35.

• Marshall, M. N. (1996). Sampling for qualitative research. Family practice, 13(6), 522-526.

• Riyami, A. A. (2012). Health Vision 2050 Oman: A Committed Step towards Reforms. Oman Medical Journal, 27(3), 190- 191. doi: 10.5001/omj.2012.43

• Safian, S. C. (2012) Factors Influencing Students to Enroll in Health Information Management Programs. Longwook, FL: Capella University.

• Sandefer, R., DeAlmeda, D., Dougherty, M., Mancilla, D., & Marc, D. (2014). Keeping Current in the Electronic Era. Journal of AHIMA, 39-44.

• Sandelowski, M. (2000). Focus on research methods combining qualitative and quantitative sampling, data collection, and analysis techniques. Research in nursing & health, 23, 246-255.

• Shepheard, J. (2010). Health Information Management and Clinical Coding Workforce Issues. Health Information Management Journal, 39(3), 37-41.

• Sheridan, P. T., & Smith, L. B. ( 2009). Redefining HIM Leadership: Toward an HIM Leadership Framework: A Commentary on HIM Leadership. Perspectives in Health Information Management / AHIMA, American Health Information Management Association, 6(Summer), 1c.

• Street, T. (2012). Creating change in the health information management profession. Health Information Management Journal, 41(1), A20-A20.

• Watson, P. J. (2008). Health information management in Australia: a brief history of the profession and the association. Health Information Management Journal, 37(2), 40.

• Watzlaf, V. J., Rudman, W. J., Hart-Hester, S., & Ren, P. (2009). The Progression of the Roles and Functions of HIM Professionals: A Look into the Past, Present, and Future. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 6(Summer).

• Zeng, X., Reynolds, R., & Sharp, M. (2009). Redefining the roles of health information management professionals in health information technology. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 6(Summer).



41

IntroductionHealth information exchange (HIE) is the electronic movement of health-related information among organizations according to nationally recognized standards. The goal of health information exchange is to facilitate access to and retrieve clinical data to provide safer, timely, efficient, effective, equitable, patient-centered care. Usually, 18% of the patient safety errors and as many as 70% of adverse drug events could be eliminated if the right information about the right patient is available at the right time. Health information exchange makes this possible. One of the most promising advantages for HIE is improved patient safety. The overarching goal of HIEs is to allow authorized users to quickly and accurately exchange health information to enhance patient safety and improve efficiency.

What is Health information exchange (HIE)?HIE is the mobilization of healthcare information electronically across organizations within a region, community or hospital system. In practice the term HIE may also refer to the organization that facilitates the exchange.

HIE allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care. Appropriate, timely sharing of vital patient information can better inform decision making at the point of care and allow providers to:

• Avoid readmissions

• Avoid medication errors

• Improve diagnoses

• Decrease duplicate testing

Health Information Exchange: An Overview of Improving Health Care & Patient Safety

Madhu Mohan MaddiralaMedical Records Officer

Tata Memorial Centre, ACTRECGovt. of India, Mumbai.

Email : [email protected], Cell: 09920978102

There are currently 3 key forms of health information exchange:

• Directed Exchange: Ability to send and receive secure information electronically between care providers to support coordinated care

• Query-based Exchange: Ability for providers to find and/or request information on a patient from other providers, often used for unplanned care.

• Consumer Mediated Exchange: Ability for patients to aggregate and control the use of their health information among providers. The foundation of standards, policies and technology required to initiate all three forms of health information exchange are complete, tested, and available today.

What are the benefits and risks of HIE?• The manual printing, scanning & faxing of

documents, including paper and ink costs, as well as the maintenance of associated office machinery.

• The physical mailing of patient charts and records, and phone communication to verify delivery of traditional communications, referrals, and test results.

• The time and effort involved in recovering missing patient information, required to recover such information.

Proponents claim that electronic health records and HIE will revolutionize medical practice. Not only will they improve the quality of health care, but they will also increase efficiency and reduce costs. The idea is that once a person’s medical records are electronically and available to every provider he sees, treatment will be better, safer, and more effective because it will be based on the complete record. In addition,



42

overall costs will go down because providers will be able to eliminate redundant diagnostic tests, procedures, and prescriptions no need to re-invent the wheel.

• Improved quality of care.

• Reduction in medical errors.

• Decrease in redundant or unnecessary services and tests.

• Reduced administrative and clinical costs.

• Ability to track who accesses medical records, including when and why.

• Improved monitoring of chronic conditions.

• Increased patient engagement in their care when patients can access their own health information.

It will be some time before we know whether the benefits of electronic health records have been oversold. However, it is clear that HIE will increase the exposure and vulnerability of everyone’s medical information by making individual medical information universally available. The medical information is already widely exposed. The healthcare industry’s non-standardized and duplicative recordkeeping and billing procedures generate multiple records containing personally identifying information in the course of treatment and payment. In addition, third parties and contractors have access to personal medical information in order to perform many non-treatment-related functions on both the provider and payer sides of healthcare.

When electronic medical records are universally available, the number of locations and people accessing the information will increase. Even with access controls, technical security, and data breach laws and regulations, increased accessibility will increase the risk of medical identity theft and large-scale medical financial fraud. It also increases the likelihood that errors entering a medical record are replicated. Errors may enter a medical record when someone makes data entry mistakes, inadvertently or negligently mixes records, or commits medical identity theft.

How does HIE work?Health information exchange is a work in progress, but the first step is transitioning from paper to electronic records (computer files). Healthcare providers of all sizes—from a small practice to a large medical centre must purchase an electronic medical

records system (EMR) to computerize their records. The computerized records are called electronic health records (EHRs).

Once it has electronic records, the provider will likely contract with an HIE or HIO so it can exchange medical data with other providers. Providers may directly request records from other providers, called a “point-to-point” solution. But having an HIE or HIO in the middle to facilitate the transaction seems to have become the standard practice.

HIE and increased patient safety1. Improved medication information processing:A. Improved medication information processing with

regard to patient safety, medication information processing probably represents the most studied area of HIE today.

Improved Patient Safety through HIE

• Improved Medications Information Processing.

• Drug-Allergy Information Processing.

• Drug-Dose Information Processing.

• Drug-Diagnosis Information Processing.

• Drug-Genetic Information Processing.

• Improved Laboratory & Radiology Information Processing.

• Improved Provider to Provider Communication.

• Improved Patient to Provider Communication.

• Improved Public Health Information Processing.

B. Drug-allergy information processingOne of the most obvious forms of medication information processing for patient safety is drug-allergy processing. This involves checking drugs against known patient-specific drug allergies before the drugs are given to the patient.

C. Drug–dose information processingDrug–dose information processing helps improve patient safety by helping to ensure that the individual dose, daily dose, and total dose will minimize toxicity while providing therapeutic efficacy. Drug–dose information processing involves being sure that the individual dose, dosing frequency, and total duration of medication fall within accepted general standards.

D. Drug–drug information processingThe most robust medication information processing currently occurs at the drug–drug level. This support can significantly improve patient safety, but it will



43

be most effective only if the entire list of all of a patient’s medications, including over the counter medications.

e. Drug-diagnosis information processingDrug-diagnosis (drug–disease) information processing is an expanding area in which enhanced HIE has the potential to improve patient safety. In some ways an outgrowth of patient-specific drug–dose information processing, drug diagnosis information processing takes into account medical conditions and contraindications that would affect drug dosing or administration at all.

f. Drug–gene information processingAlthough not currently a reality, as gene analysis becomes more prolific and pharamocogenomics becomes more developed, the ability to interchange drug information and patient-specific genomic information will become increasing important for patient safety. HIE in this area has the potential to optimize pharmaceutical choices to avoid/reduce ADEs and other side effects, as well as optimize effectiveness.

2. Improved laboratory information processingThe two primary areas for this include (1) helping to ensure that indicated lab testing is ordered and (2) helping to guarantee that lab test results (especially abnormal results) are appropriately followed up on. HIE is particularly critical in this process in this era of few in-office tests, many ‘‘send-out’’ tests, and numerous independent laboratories.

3. Improved radiology information processingTypically the provider ordering an imaging study is different from the provider interpreting the imaging study. Therefore, health information has to be exchanged between these two health professionals for the radiology study to be effectively ordered and interpreted. Patient safety can be enhanced in both of these areas of radiology information processing through improved HIE.

4. Improved communication among providersMany healthcare scenarios exist in which patient safety is jeopardized because of lack of HIE among providers. Patients routinely present to emergency departments outside of their normal healthcare

system, sometimes unable to communicate, where their providers may have little or no prior information about them. Providers who do not know the patient, either in an inpatient or outpatient setting, make safer decisions with improved HIE.

5. Improved communication between patients and providersInclude patients checking for errors in their medical medical history, adding additional valuable information into their medical records, following up on their own test results, reviewing medications and other healthcare instructions, and being able to communicate more quickly with healthcare providers when they think their safety may be at risk

6. Improved public health information processingA rapidly growing area of HIE is public health informatics. Patient safety could be greatly enhanced through this growth. Opportunities for improved patient safety in this area include post-marketing drug surveillance, infectious disease surveillance, biohazard surveillance, and environmental exposure surveillance.

7. Standards for HIE and patient safetyFor robust, efficient HIE, standards must be developed dictating the type and content of information to be exchanged. A prototypical example of this is the near ubiquitous

proliferation of PACS (Picture Archive and Communication Systems) standards within the field of radiology. Allergy, medication, laboratory, diagnostic, and notes messaging standards must be developed and implemented with a similar degree of rigour in order for equivalent HIE in these other areas to yield similar results.

8. Completeness of information for HIE & patient safetyAs electronic HIE increases, health professionals run the risk of assuming that all information is being exchanged and everyone is having their information exchanged. Systems currently in place for dealing with paper records and/or dealing with people who opt-out of HIE networks (for instance Regional Health Information Organizations (RHIOs)) may not continue. Therefore, our ability to process health



44

information in patients who have some health Information that is not readily exchanged and/or to deal with patients who do not want their information exchanged may decrease and these patients could potentially see their patient safety eroded. Health Information Portability Accountability Act (HIPAA) is currently not robust enough to address the multiple consents that patients would require should an HIE want to use clinical data for research purposes.

ConclusionAs more and more healthcare information becomes digital, the potential for HIE to improve patient safety will grow, and it is already robust. One challenge will be to develop healthcare systems capable of processing and utilizing the dramatic increase in information. Only then will the potential of improved patient safety through enhanced HIE be realized because we will have increased the percentage of time that the right information is presented to the right person at the right time so that the right healthcare decision can be made. The United States is investing heavily in HIE to improve health care quality and cost effectiveness. We can encourage future research that addresses HIE technical barriers that currently exist, such as security, improved end user data displays, and patient-centred HIE mechanisms.



45

Transformation of Healthcare with Electronic Health Records (EHR) Opportunities and Challenges

Md. Zakir HussainSr. Manager Medical Records

Basavatarakam Indo American Cancer Hospitals and Research Institute, Hyderabad



46



47

Introduction:The healthcare industry is undertaking a structural change by aligning Health Information Technology (HIT) with the delivery of care to improve quality, control costs, and enhance the efficiency of the system.

Health care organizations are promoting coordinated care to improve care and create savings. The health funders are moving away from Fee for Service reimbursement methodology to risk sharing and prospective payment models.

A majority of the Health care Organizations have realized the importance of Health Information Management (HIM) and their expectations are also growing day by day. The Hospital management expects Health Information Managers to assume leadership roles and be part of the senior management team to support them in providing facts for business opportunities, clinical care improvement, efficient Revenue Cycle Management etc. This has lifted the status of the HIM professional to a new level, with different dimensions of roles and functionalities.

HIM Role and Challenges:In order to adhere with these changes, the present day role of HIM’s role is expanded to managing Medical records, studying health system to assist the Health IT to implement EMR, playing a pivotal role for planning and executing data collection and performing big data analytics, educating physicians and care providers on documentation needs and providing extensive support in revenue cycle management.

The HI Manager has lots of challenges in the day to day working of the organization and at the same time opportunities are also abundant in the present day Health Information Management market. HIM

Challenges of HIM Professionals with Emerging Technology and Reimbursement Models

Narendar Sampath Kumar,MBA (Hospital Management), Masters in Population Studies,

BMRSc, PGDCS, CHRIM (U.K), CCS, CCA (AHIMA)Health Information Manager,

MEDICLINIC MIDDLE EASTDubai, United Arab Emirates

professionals have to face the challenges tactfully to progress. Challenges can be classified as Ethical, Health IT, Information Governance, Coding & Revenue Cycle Management, Data Analytics and Health care Finance.

Ethical Challenges:Due to the continuous advancement and changes in the medical record documentation process, e.g. from paper based to electronic formats etc, the HIM professionals have to be aligned with the changes and ensure that the fundamentals of documentation guidelines are followed. This can be achieved by having continuous audits and quality assurance programs involving all the health care providers. Although technology is taking over traditional methods, HIManagers have to be vigilant and ensure that medical record documentation principles such as quality, timeliness, etc. are managed properly.

Information Technology (IT):With the digitizing of information systems in healthcare organizations, the role of HIM professionals have expanded into information technology (IT) and user support, which usually are the functions of IT support services. HIM professionals’ training and experience in the intersection of clinical and management sciences as well as their knowledge about data quality equip them with the capability to maintain the integrity and accessibility of health information, although they may not necessarily have the particular skills to support technical operations of information technology systems.

Implementing Electronic Health Records:A Health Information Manager will have to play a crucial role in software and vendor selection, as 80% of Health Information Systems are utilized by the HIM department. Changes are pervasive,



48

and many practices are ill prepared for the future, especially those lacking information management and technology support. HIM professionals could be great support to the institutions with their HIM skills in transforming the paper records into paperless or to electronic record systems. HIM professional has to involve in the complete system development life cycle starting from documenting the requirements, system designing to suit the needs of health care providers with user friendly processes, till User Acceptance Testing. By this system, proper registration, scheduling, patient visit, pre-certification documentation, coding, and payment can be maintained.

Coding & Revenue Cycle Management (RCM):Healthcare is undergoing a fundamental shift from fee-for-service to value-based delivery and payment, creating a wrenching change in the markets. As you are all aware, accurate clinical documentation and coding reflects the actual care rendered which in turn represents the accurate reimbursement.

Getting it right at the first time is the biggest challenge in RCM. In order to achieve this, HIM professionals have to multi-task and monitor right from the beginning of the care until the claims are submitted. This whole cycle involves Identity Management, Access Management, Documentation Management, and Revenue Management. Health Information Management has to be very vigilant to ensure the coding processes are carried out accurately by conducting regular audits and be an active member in clinical documentation improvement teams.

Information Governance:Though Electronic Medical Record is implemented widely, no hospital could achieve complete paperless medical records, instead it is less paperless record. Scanning and uploading of information, information through the medical equipment, etc, lead to a decentralized, isolated approach of information gathering which increases risk, duplication and cost though the information is stored in the electronic medium and reduces the storage and retrieval costs.

The generations old role to be the custodian of Medical Records have expanded now with emerging technologies as the HIM needs to develop the information governance policy meticulously taking into consideration the access rights, gathering

patient information from various sources and collating it as part of the EMR and managing it safely and confidentially,

Data Analytics:The reason for Health care Organizations to dependent on big data is to harness it, understand it and use it to cut costs, create more predictive healthcare and improve outcomes. The data analytics software available in the market gives more granular information with 360 degree view. The basic element of health care data originates from the HIM department, right from the demographic, administrative, clinical, coding data and the results. Hence the HIM professionals have to spend a majority of time to ensure data collection, process, storage and analytical tools are properly managed and the required management information reports are generated regularly. Apart from regular reports generated by other departments, HIM being the bridge between administrative and clinical units of the health care organization, HIM professionals can help identify opportunities for the use of this data to improve business intelligence, clinical care, and decision-making throughout the organization.

Challenges of operating cost with decline income:Medical practices and health institutions are in transition in information management and technology as mentioned earlier; hence the HIM professionals have a big role to play during and beyond transition to electronic health records. The top challenges are increasing operating costs and waning reimbursement topped the list. This means spending more and getting less, if, this practice continues, the practitioner or the institution will be insolvent. The government institutions or hospitals are subsidized for the healthcare expenditure, while all the private practitioners and corporate hospitals, even though established with non-profit basis, have to survive and sustain the financial burden, otherwise will result into a low quality practice.

Cost justification:HIM professionals working in small practices or big health institutions can research, help determine cost justifications, and support management in providing cost effective care. HIM professionals can help in ensuring compliance, analyze data and map clinical



49

pathways and do utilization review. Firstly, an HIM professional can become well-versed on all aspects of electronic records; their cost, benefits, impact on workflow and efficiency, and revenue potential. It is the HIM’s endeavor to show healthcare providers how they can save time, efforts, reduce operating cost, and sustain improved quality of care. Where there is a lack of good record system or inefficient management, there is a problem of declining reimbursement and increased operation cost. HIM professional plays an important role in bringing complete and relevant information coupled with efficiency of practice for prudent decision making are ways to successful implementation. Despite HIM not being IT educated, he is an expert in maintaining proper content, documentation and workflow that can make a great difference and this knowledge serves as a valuable resource to help others to understand the importance of proper documentation, confidentiality, professionalism, and optimal care with the electronic record system.

Healthcare Financing: The transition from traditional reimbursement models and toward pay-for-performance and Prospective Payment System will constitute a major paradigm shift for physician practices or health institutions.

The concept of the Prospective Payment System (PPS) is to have a cost fixed for homogeneous patient groups which are based on the documentation and coding. The Health Information Management team lead by the Manager, supported by the Clinical Documentation Improvement Specialist, Coders, Case Manager play a crucial role in case management, discharge planning which are the integral parts of the PPS. The intricacies of the clinical documentation and the coding will enable physician or hospital to receive accurate reimbursement.

HIM professional undertaking research:HIM professionals can help by researching and undertaking some case studies related to the subject. The abundant of information that technology supports, has revolutionized the image of many organizations and healthcare is one of them. With this facility, the HIManager can play a good leadership role in improvements for financial benefits. Whenever, we suggest improvements, financial benefits etc., it needs to be provided with

meaningful data in terms of workflow and financial benefits to demonstrate the value of HIM field to the healthcare providers with all the justifications.

Leading the Team:Leadership skills are vital for Health Information Managers to excel in their profession. It is one of the important skills in educating personnel and advocating for products and procedures that enable the organization to provide quality care is possible. In a time of great transition for medical practices and health institutions, HIM professionals must be ready to change also. HIM professionals adopt a leadership framework that understands the emotional and mutual interdependence of workplace systems, the importance of effective relationships, and the effect of anxiety on an individual and organizational performance. To be successful, one has to be creative and adaptive to a constantly changing environment that requires the ability to assume leadership in multifaceted roles such as HIM practitioner, manager, educator, researcher and consultant.

HIM Preparedness: HIM professionals have to be abreast with current knowledge in clinical coding, data analytics, information governance, quality assurance and health costing to meet the needs.

AHIMA and other related Health Information Management associations, universities around the globe offer online courses to get the required qualification. Apart from the basic HIM qualification, one should dive deep and learn to the core of super specialized HIM skills such as Privacy, Auditing, Revenue Cycle, Clinical Documentation, Health Data Analysis etc. to competently face the present day HIM challenges.

Conclusion: HIM professionals have to work with passion, dedication, and be a Good Samaritan. HIM professionals have to widen their focus and broaden their horizons. Everyone has to work dedicatedly and wait to seize the opportunity to prove their skills and climb the professional ladder. There are no shortcuts, the greater the efforts, better the future will be.

The role of a HIM profession is like the hub of the healthcare delivery wheel that has a central repository of rich information, and uses intellectual



50

skills to explore the information and provide vision to the organization.

Every challenge we meet on field is an important learning curve in our professional life. The more challenges we face, better we are equipped. In this respect, I am grateful to Dr. G.D. Mogli, under whom I worked. With him I have learned various technical and administrative skills that have helped to grow from an Assistant Medical Record Officer position to my present position as corporate HIM manager at Mediclinic Middle East which is one of the top 10 listed private hospital groups in the world. Member of Funder Relations team with main focus on managing HIM, coding, assisting revenue cycle management, e-claims, tariff development, analyzing and studying the case mix trends for business development.

I am sincerely thankful and obliged to the Mediclinic Middle East Senior Management Team, Mr. David Hadely, Chief Executive Officer, Dr. Pietie Loubser, Chief Clinical Officer, Mr. Hein Van Eck, Head, and Funder Relations Department for their support,

guidance and their confidence and trust in me, which helped me to implement various HIM processes successfully and grown professionally.

I would like to take this opportunity to thank Dr. G.D. Mogli, President and HIMA governing committee members for giving me an opportunity to present this paper.

References:• Role of Associate of Health Information for Care, Cost and

Quality Assurance in the Millennium by Dr.Mogli & Mogli

S.K. Present in 13th International Health Record Congress,

2nd t 6th October, 2000, Melbourne, Australia

• HIM Professionals’ Endurance in 21st Century, Proceedings

of 14th International Health Records Congress, November

2004, held at Washington, DC, USA., by Dr. G.D. Mogli

• Information Governance in Healthcare–Benchmarking

White Paper- Cohasset Associates – AHIMA

• Data Retrieval, Analysis, and Reporting Skills are Critical for

HIM and Health Information Technology Professionals – UW

HIMT BLOG



51

Key words:Delayed Discharge, Pre Discharge planning

Background: Nizam’s Institute of Medical Sciences (NIMS) is a 1300 bedded autonomous super specialty tertiary care teaching institute located in Hyderabad, India. NIMS have a high bed occupancy rate and there is a constant pressure on the administration for the want of vacant beds. In such a scenario, delay in the discharge process adds further stress to the situation.

Introduction:Discharge from the hospital is the point at which the patient leaves the hospital & either returns home or is transferred to another facility such as one for rehabilitation or to a nursing home. Remaining in hospital beyond the necessary time has long been a concern, contributing, as it does, to reduced care quality and increased costs1.Bed pressures are increased by ‘delayed discharges’, which exacerbate patients’ exposure to hospital-acquired infections, low mood and increasing loss of functional capacity2.Delays in hospital discharge (HD) occur in the majority of hospitals (rates vary between 13.5% and 62.0%)3,4,5.Studies have identified causes and measured days of delay in Hospital Discharge4,6,7 and proposed methods for quantifying the number of unnecessary days of hospitalization. One hospital has recently reported a reduction in average inpatient stay coincident with the introduction of twice-daily consultant ward rounds8. Hospital could increase its effective capacity by making more efficient use of existing bed space and by establishing a daily routine for forecasting and executing discharges.

Though the cause for delayed hospital discharge is due to clinical and administrative causes, this study

A study on the administrative delays in the patient discharge process and subsequent reduction achieved after implementation of Pre discharge planning in a Tertiary Care hospital in South India.

Dr. N Lakshmi Bhaskar1, Dr. A Sainath Reddy2, Dr. M. S. Siddarth Sai3, Dr. Mohd Aamir Osmani4

Asst.Prof, Dept. Of HA, Nizams Institute of Medical Sciences.Junior Resident,Dept. Of HA, Nizams Institute of Medical Sciences.Senior Resident, Dept. Of HA, Nizams Institute of Medical Sciences.Senior Resident, Dept. Of HA, Nizams Institute of Medical Sciences

focuses only on the administrative aspects of the delay.

Objectives: 1. To identify the time that is being taken for the

discharge of a patient after he is clinically certified for discharge.

2. To identify the causes of delay, if any in the discharge process due to administrative procedures.

3. To implement the technique of pre discharge planning on a pilot basis on a small group of patients and to ascertain its benefits.

Methodology:Time-motion study is a business efficiency technique combining the Time Study work of Frederick Taylor with the Motion Study work of Frank and Gilbreth

Based on the above, Direct Time Study procedure was developed by Groover9 and this was used for the study. The study consists of the following components.

• Define and document the standard method.

• Divide the task into work elements.

• Time the work elements to obtain the observed time for the task.

• Evaluate the worker’s pace relative to standard performance, to determine the normal time.

• Apply an allowance to the normal time to compute the standard time.

After the first part of the study a technique called Pre discharge planning was implemented. This was done on a pilot basis for a small group of patients. Time motion observations were recorded post intervention.

The study was done in Nizam’s Institute of Medical



52

Sciences during the period of July to September, 2015.

Patients present in the general wards of departments General medicine and Neurosurgery was selected for the study.

Pre intervention Sample size of the study: 50

Post intervention Sample size of the study: 30

Personal Interviews were conducted with the concerned consultants and ward sisters.

Observations:Steps of Discharge flow in NIMS:

1. Discharge advised by the treating consultant

2. Department’s Resident (PG student) manually writes the discharge summary.

3. Written Discharge Summary is sent to the Dept’s Typist/Computer operator.

4. Typed Discharge Summary and Investigation Reports are given to the patient’s attendee and he is asked to get Xerox copies of the same.

5. Sister files the case sheet with the discharge summary and reports and sends it to the main billing section in the old block.

6. Billing section prepares the bill and informs the patient regarding the amount.

7. Patient’s attending pays the required amount in the adjacent cash counter and submits the receipt in the billing section.

8. On receiving the payment receipt, No dues slip is generated and given along with the detailed bill of the patient.

9. No due is submitted to the sister, after which the patient is discharged from the ward.

Average Time taken for each step of the discharge process before the implementation of Pre discharge planning:

Step 1:

• Discharge is advised by the consultant during his daily rounds (mostly done at around 9 to 10 am)

Step 2:

• 4 hours

• This is the step which has the highest time lag in the discharge process.

• It was observed that there is no uniformity on when the summary is written.

• On certain instances it was done immediately after the rounds and on certain instances it was done post lunch (3 to 4 hours after the advice by the consultant).

• It was observed that residents of surgical depts. write the summary in the evening (7 to 8 hours after the discharge advice by the consultant). This was observed on the OT days of the surgical depts.

Step 3:

• 1 hour.

• It includes the patient’s attendee taking the written summary to the typist, the typist entering the data in the system and giving a print out to the attendee and the attendee submitting the same to the sister.

Step 4:

• 1 hour 30 minutes.

• It includes the time taken by the patient’s attendee to take investigation reports and discharge summary to the Xerox shop (located on the main road outside the main block), time taken in the Xerox shop and the time taken for the attendee to return to the ward.

• Abnormal delays were noted in certain instances which were attributed to the power cut forcing the attendee to wait till the power came on.

Step 5:

• 30 minutes.

• This step includes sister giving the case sheet to the worker and asking him to submit the same in the billing section.

• Delays were noted in certain instances where the worker was sent for other work and the sister had to wait for the worker to return.

• It was also observed in some instances that the sister waited before allotting two to three tasks to the worker while sending him to the billing section.

Step 6:

• 2 hours 30 minutes.

• Longer delays were seen in cases with a higher duration of stay. This was attributed to the fact that the billing clerk had more entries to make in such cases.

• It was also observed that there was a delay in the



53

billing in the evening time due to increased load at those hours.

Step 7:

• 45 minutes.

• Delays were observed in instances where the patient’s attendee had to go to the ATM counter to draw money.

Step 8:

• 20 minutes.

Step 9:

• 45 minutes.

• This included the attendee taking the no due slip and submitting it to the sister, sister making entries in her book, sister explaining to the patient their future course of action, and the patient leaving the ward.

• Delays were observed in instances where the patient was waiting for ambulance or for relatives to arrive.

Total time: 11 hrs

Intervention:Interventions implemented at the various steps:Interventions at Step 1:

• Consultants were asked to forecast the discharge of the patient if possible a couple of days in advance.

• Consultants were asked to advise the patients regarding cross consultations like dietary, physiotherapy prior to the discharge day, if possible.

• Consultants were asked to start the rounds early in the day.

Interventions at Step 2:

• Residents were asked to write the basic skeleton of the discharge summary before the actual discharge day.

• Residents were asked to write the discharge summary immediately after the rounds of consultant.

• Consultants were asked to not to allot any other work to the concerned resident and allow to him to finish writing the discharge summaries.


• Typist/ Computer operator was asked to prepare a common format for discharges and store the

same for repeated use.

• Typist was asked to start entry of the discharge summaries as soon as they arrive and not wait for all of them to arrive before starting.


• A Xerox machine counter was placed in the old building with nominal charges.


• Sister was asked to collect all the pending investigation reports, if any, before the day of actual discharge.

• Sister is asked to send the case sheet to the billing section as soon as it is ready and was also asked to prepare the schedule of the worker in the same way.

• Workers were also instructed to not waste time and go to the billing section immediately after receiving the case sheet.


• Sister was asked to send the case sheet folder to billing for entry/accounting before the day of actual discharge so that most of the entries in the billing section are already done.


• Sister was asked to inform the patient regarding the approximate bill amount prior to discharge day so that the patient would make arrangements for the same.


• No interventions suggested.


• Sisters were asked to explain to the patient regarding the future follow up and clarify all their doubts and not wait till the time they are about to leave.

Observation and Results after Implementation of interventions:

Average Time taken for each step of the discharge process after the implementation of Pre discharge planning:

Step 1: Discharge advice given in the morning.

Step 2: 2 hours

Step 3: 30 min

Step 4: 30 min



54

Step 5: 15 min

Step 6: 30 min

Step 7:20 min

Step 8:20 min

Step 9: 30 min

Total time: 5 hrs

Conclusion:The present study dealt with administrative delays in the patient discharge process at Nizam’s Institute of Medical Sciences. Pre-intervention the average time taken for discharge was 11 hours. Post intervention with implementation of pre discharge planning there was a drastic reduction in time to 5 hours. This reduction in time will lead to increased patient satisfaction and better turnover of beds which in turn will lead to increase in hospital revenue.

References:

1. Lim SC, Doshi V, Castasus B, Lim JKH. Factors causing delay in discharge of elderly patients in a acute care

2. hospital. Ann Acad Med Singapore. 2006;35(1):27-32.

3. P Hendy, JH Patel et al. In-depth analysis of delays to patient discharge: a metropolitan

4. teaching hospital experience. Clinical Medicine 2012, Vol 12, No 4: 320–3

5. Anderson P, Meara J, Brodhurst S, Attwood S, Timbrell M, Gatherer A. Use of hospital beds: a cohort study of admissions to a provincial teaching hospital. BMJ. 1998;297(6653):910-2.

6. Carey MR, Sheth H, Braithwaite S. A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service. J Gen Intern Med. 2005:20(2):108-15.

7. McDonagh SM, Smith DH, Goddard M. Measuring appropriate use of acute beds: a systematic review of methods and results. Health Policy. 2000;53(3):157-84.

8. McClaran J, Tover-Berglas R, Glass KC. Chronic status patients in a university hospital: bed-day utilization and length of stay. CMAJ. 1991;145(10):1259-65.

9. Panis LJGG, Gooskens M, Verheggen FWSM, Pop P, Prins MH. Predictors of inappropriate hospital stay: a clinical case study. Int J Qual Health Care. 2003;15(1)57-65.

10. Ahmad A, Purewal TS, Sharma D, Weston PJ. The impact of twicedaily consultant ward rounds on the length of stay in two general medical wards. Clin Med 2011;11:524–8.

11. Groover, Mikell P. (2007). Work Systems and Methods, Measurement, and Management of Work, Pearson Education International



55

Difference between ICF & ICDIO Codeing

I. T. KallesharaM.A, D.M.R.T., D.C.A., D.M.R.O., (JIPMER Pondicherry)

Medical Records DepartmentAyjnihh Bandra West, Mumbai - 400 050



56



57

Introduction: The Medical Record is the “Who, What, Why, When and Where? of patient care in the hospital”. With the advancement in medical knowledge and the complex nature of medical and surgical treatment in hospitals today, an accurate and adequate medical record is essential as a documentary evidence of the care and treatment which the patient received in the hospital.

Fig. 1.5

Hospital medical records can be documentary evidence as per the laws existing in different countries and they are generally subpoenaed to court in the following types of cases: 1. Insurance Cases 2. Workmen’s compensation cases. 3. Personal injury suits. 4. Malpractice Suits 5. Will cases 6. Income tax act. 7. Certificate of birth and death 8. Criminal cases 9. Medical Certificate of various types such s out-patient attendance, hospitalization, disability, fitness and so on. 10. Identification of patient etc.

The medical record is both a personal document and an impersonal document. As a personal document, the record identifies the patient by name and presents physical findings and treatment given. Such information is confidential; no one is allowed access to the record (not even next of kin) and no information is released without the written authorization of the patient. As an impersonal document, the patient’s record is utilized for research or educational study and authorization from the patient is not mandated unless the patient will be specifically identified in reports or publications emanating from these scholastic endeavors.

Medical Legal Aspects of Electronic Health Records (EHR) from HIM Perspective

Dr. G. D. Mogli, Ph.D., MBA. FHRIM (UK), FAHIMA (USA)Visiting Professor, Medical Informatics, MGM Sciences, Maharashtra, India

Ex. World Health Organization [email protected] and www.drmogli.com

Fig. 4.1 Fig. 4.2

A court of law has the right to summon patient medical records of patients. Records are not to be handled by anyone except those authorized as determined by the hospital.

Medical Legal Cases (MLC) Registration: Medical legal register: There should be a central medico- legal register kept in the Accident & Emergency (Casualty) Department under the supervision of the Chief Medical Officer. All medico-legal cases admitted from casualty, outpatient, and inpatient services should be registered in the central medico-legal register. A medico-legal stamp should be affixed on each registered case to ensure that the case has been registered. The completed central medico-legal register should be kept under the custody of the Medical Record Officer. All medico-legal cases registered in the hospital must be communicated to the police through the hospital administrator to ensure that the medico-legal case records are complete. These cases should be kept under safe custody of a responsible officer in the Medical Record Department.

Fig. 4.3

Temporary permission to leave the hospital: As a policy, any patient who is hospitalized should not be permitted to leave the hospital. At the discretion of the treating doctor, the patient may



58

be permitted to leave the hospital temporarily for a period of not more than 24 hours. If permitted and the patient fails to return within 24 hours, he or she should be treated as discharged and the necessary entries made in the record. In the case of patients, who return according to schedule, necessary entries of date and time of leaving and returning to the ward should be made in the patient file.

Consent: Written consent must be obtained from the patient or nearest relative for medical examinations, investigations, treatments, and procedures performed in the health care facility. In the case of children, persons of unsound mind, unconscious patients, and the consent of the guardian, the spouse or the nearest relative may be obtained. The consent of the husband is required if an operation deprives his wife of her marital functions.

General Consent:General Consent relating to medical examination, investigations and treatment must be obtained by the admission office as routine, in all cases admitted to the hospital.

Special Consent:Special Consent in addition to a general consent, obtained for surgical procedures (operations), amputations, sterilizations, patients leaving against medical advice, donations of organs, post-mortem examinations, etc. These must be obtained by the ward nurse in the presence of a witness. The legal responsibility is shouldered by the treating or operating surgeon.

Emergency Operation:Emergency operation procedure which has to be performed to save the life of a patient (for whom consent was not possible), this should be written in the patient medical file “an emergency operation is essential to save the life of patient and cannot be delayed” and should be signed by two physicians including the operating surgeon and the hospital administrator or his representative.

Patient leaving the hospital against medical advice:If a patient is discharged against medical advice, the signature of the patient or nearest relative should be

obtained in a prescribed form. The patient or nearest relative should be informed of the consequences or risk involved and the hospital is not responsible for any adverse effects. In the event the patient or nearest relative refuses to sign a release, the patient record should contain a statement signed by the physician and duly witnessed setting forth the circumstances, reasons, and warnings against such premature departure.

Release of Information: Confidentiality: Medical records and health information whether in verbal form or written documentation pertaining to any identified patient is confidential. As such the information available either in the form of medical records, disease and operation indexes, computer stored data, microfilm, photographs, videotapes, audiotapes, or any other device used for these purposes should be treated as confidential documents Therefore, only authorized staff are allowed to deal with such patient information.

Authorized staff: Those who are involved in taking care of the patient, normally including medical, nursing, and paramedical personnel as well as the staff of the Medical Record Department.

Release of information without the patient’s permission:

Conditions: (e.g. injuries, poisoning, abortions, or cases involving accidents, suicides, and homicides) must be reported to the police or other legal authorities.

Communicable and other notified diseases: must be reported to the concerned authorities.

Events (births, deaths, fetal deaths): must be reported to civil registration authorities, either directly or through family members.

Court order: The hospital is also obliged to provide information in response to a court order. All reports may be made available to the court without the patient’s permission.

Medical records and health information: are the properties of the hospital, therefore, all correspondence for medical information on patients in the hospital will be handled by the hospital administrator or his authorized representative. This includes insurance forms, workmen’s compensation



59

forms, medical certificates, letters to schools or places of employment, government forms, questionnaires, requests for case summaries from attorneys and courts of law, etc. The physician is not permitted to release any information except information related to patient care. Any request for information including medico-legal cases must be referred to the hospital director.

Removal of medical records and health information: The informational content of the medical record must be safeguarded against loss, defacement, tampering, or use by an unauthorized person. Only authorized employees have the right to read or copy the contents of any patient’s record. Any violation of the rules of confidentiality should be prosecuted and punished as per the existing laws.

Impact of the Consumer Protection Act in Medical Field:

Since1986, the protection act came into existence the healthcare providers including doctors, nurses, paramedics and hospital administrators have to be meticulously careful in understanding the full responsibilities that they have to fulfill in the legal and administrative sense.

Who is Consumer? The paying patient, who receives health services from clinics, health institution, nursing home, etc., is considered to be the consumer.

Why the Consumer Protection Act? The statute has been enacted to provide for better protection of the interest and for that purpose consumer council have been established.

What is Service? It is defined as medical/health service of any type receive in any recognized health institutions, clinics, nursing homes from a qualified medical, nursing, paramedical professionals by a patient.

What is Deficiency: Under the Act, deficiency in relation to any service means any faults, imperfection, short coming, and inadequacy, in the quality, nature and manner of performance which is required to be maintained under law.

Medical Malpractice/Negligence: This could be distinctly divided into two categories primarily due to incompetence and mere negligence, secondly due to non-maintaining organized patient record.

Medical practice under the law is more than mere error in treatment or diagnosis. To be judged to be

malpractice there must be serious harm caused in the patient as a direct result of the error. Furthermore, the error must be one caused by negligence of the healthcare provider.

The medical record is the basic reference document used in medical malpractice litigation. The poorly written, disorganized record is strong evidence of an incompetent healthcare provider. The poorly kept record is not, in itself, of negligence on the part of the healthcare provider, but it is proof of substandard care. The least credible records are those that are internally inconsistent, e.g., the situation where doctor’s progress notes indicating ‘patient doing well, while nursing notes indicates patient had developed high fever.

Legal aspects of Electronic Health Records: Electronic health records play an important role in efficient healthcare delivery system that is being adopted worldwide. Most of us are familiar with legal aspect of manual medical records, nevertheless, legal and ethical aspects related to electronic health records need to be understood clearly. Enhanced portability and accessibility of EHR data raises ethical questions regarding ownership of protected health information and clinicians’ responsibility to prevent and inform patients of the possible for privacy breaches. The health record is also a legal record for healthcare organizations; as such it must be maintained taking into consideration the professional practice, applicable regulations, accreditation and legal standards.

Figure 26: Patient Records of Medico legal cases

Authentication for Legal Admissibility: One important issue is that all the records must be identified and authenticated while providing the care, to be admissible in the court of law.

Testifying about Admissibility: If records of health or image to be admissible in the court of law as evidence, the rule states, “if data are stored in a computer or similar device, any printout or other output readable by sight, shown to reflect the accuracy, is an original. An accurate print out computer data satisfies the best evidence rule, which ordinarily requires the production of an original to provide the content of a



60

writing, recording, or photograph.

Authorship: Generally, the healthcare provider who records the information as part of treatment is the origination of recorded information. Authors are responsible for the completeness and accuracy of their entries in health record. If the entries are made by a second person e.g., a nursing staff on behalf of care provider (physician), the treating physician is responsible for the content, accuracy and completeness of document.

Authentication of Entries: All entries documented including event, condition, opinion, advice, by the care provider in health record has to be authenticated and dated.

Types of Signature: In electronic health records, the signature generally includes electronic or digital signatures or computer key. Authenticated scanned document can follow either manual (paper) or electronic guidelines.

Rubber stamp signatures: Acceptance of this system varies from country to country and is acceptable if permitted by state or central/federal reimbursement regulations.

Initials: Initials should not be used for entries where a signature is required by law. And also not to be used on narrative notes or assessment entries. Nevertheless, initials are permitted to authenticate entries such as flow sheets, treatment or medication records.

Fax signatures: The fax signatures are generally acceptable in many nations, unless the state and central /federal laws are contrary for acceptance.

Electronic Signatures: The electronic signatures are acceptable if permitted by state, central /federal, and reimbursement regulations. This varies nation to nation.

Digital signature: a digital signature provides digital assurance that information has not been modified, as if it were protected by a lock which is broken if the content were altered.

Other Documentation Issues: In the manual system, the policies of the institution are to use only authorized abbreviations in the health records by all the staff. In EHR, abbreviations should be eliminated as information is formatted. Electronic order sets, document templates for point-and-click or direct charting, voice recognition, or transcribed

documents can be formatted or programmed to eliminate abbreviations.

Cut, copy, and paste functionality: Whereas in EHR, the primary issue with cut, copy, and paste functionality is one of authorship problems. It is difficult to identify who is the author and what is the date of origination for copied and pasted entry. There are several issues like, cutting from one record and pasting in another record, lack of identification of the original author and date, and acceptability of cutting and pasting the original author’s note without his or her permission leads to many legal issues, hence, clearly laid down policies and procedures to be adopted for this process.

Link one patient, one record with one number. Each and every page in the patient record or computerized record screen must identify patient by name and health record number. Patient name and number must be on both sides of every page as well as on every form and computerized printout.

Chronological and timeliness of each entry: There should be proper flow of chronological entry; the record must reflect the continuous chronology of the patient’s healthcare. The EHR systems should have the capability of producing an output that chronicles the individual’s encounter. As regards to timeliness of an entry is vital for admissibility of a health record in the court of law.

Date and Time: Every entry in the health record must include a complete date (day, month, and year) and a time. In electronic health record systems must have facility to date-and time-stamp each entry as and when the entry is made. Every entry in the health record must have a system-generated date and time based on current date and time.

Imaged records: The standards used for manual (paper) records apply to imaged records. In addition, all scanned documents must be date-and time-stamped with the date scanned. All entries to be scanned into the record should be made in black ink to facilitate legible reproduction of records. Correcting an error in electronic computerized health record system should follow the principles laid down by the institution. The system must have the ability to track corrections or changes to the entry once the entry has been entered or authenticated. When correcting or making a change to any entry in a computerized health record system, the original entry should be viewable, the current date and



61

time should be entered, the person making the change should be identified, and the reason should be noted. If a hard copy is required to be printed from the EHR, the hard copy must also be corrected invariably with changes made.

The institutional policy must clearly define how errors are corrected in imaged documents while preserving in a readable form the original documents or image.

Retraction: this involved removing a document for standard view, removing it from one record, and posting it to another within the electronic document management system.

Late Entry: The policy must be very clear, when a required entry was not made in a timely manner; a late entry can be made by identifying the new entry as “late entry” with current date and time.

Amendments: An amendment is used to provide additional information in conjunction with a previous entry. When making an addendum; record invariably date and time in the document, write “addendum” and state the reason for the addendum with reference to the original entry and complete as soon after original note as possible.

Decision Support: This system generates notifications, prompts, and alerts, should be evidence-based validated, and accepted by organization.

Notification and Communication with Patient or Family: In the event of any discussion with patient’s family occurs regarding care of the patient, treating physician might send a notification to the family members. It is required to document all information including notification, discussion with family along with date, time and of all communications or any efforts made.

Electronic Consent: With electronic consent, the patient views the consent and electronically signs it. An organization should verify that the electronic signature or authentication protocol meets all legal and regulatory requirements.

Managing data from the patient other facilities: The organization’s policy should define whether the data in its entirety or just the data abstracted and transferred by clinician is incorporated into patient’s health record and place of its insertion to be clearly stated and the source of the clinical data should be documented. In electronic health record system, if

the medical images are received from the patient or outside health organizations, the images may be uploaded into the central clinical system and giving reference where the data located, the source of organization, author and date.

Hybrid records: Healthcare institutions should define the procedure for the transfer of clinical information received on CD or DVD or USB into the hybrid record. Options may include print to paper then image or upload into EHR or interface with the hybrid record. It must be determined whether laws, regulations, or organization policy requires retention of the original media or a photocopy.

Retention and preservation schedule: Healthcare organizations, as a policy, mush establish retention and preservation schedules for the records, images and content of the legal health record that comply with state or central /federal regulations and the needs of continuity of patient care, medical education, research, legal and other administrative purposes. For electronic health records, the electronic storage media such as magnetic and optical formats must meet the organization’s retention and preservation schedule should include retention of all types of data including discrete data, text, audio, video, and images. Clear policies should address backup procedures to ensure retention and preservation process is strictly observed to protect against data loss or damage.

Technology dynamism: Since records or data is retained for a longer duration, the technology used earlier is different from the present or future technology which is dynamic. As technology changes, and its features also different, measures must include “backwards compatibility” or some type of software that facilitate to access previous systems information for compatible with the new or upgraded system and also for future comparability.

Purging and Destruction: Generally, the nations and the institutions to have clear policy on purging and destruction of manual and electronic records.

Date Integrity: Integrity is defined as the accuracy, consistency, and reliability of information content, processes, and systems. Information integrity is the dependability or trustworthiness of information, which is a vital concept in a legal proceeding. Integrity of health record is maintained through access, network security, audit trail, security, and disaster recovery processes.



62

Health Record Access Control: Health record access control is critical to avoid access of unauthorized persons. This process determines the policies of authorized persons to access patient information in the health record. Controlling access is an important aspect of keeping the legal integrity of the health record.

Audit Trail: Element of an audit trail may include date, time, nature of transaction or activity, and the individual or automated system linked to the transaction or activity. Transactions may include additions or edits to the health record. Activities include access to view or read, filing, and data mining. Audit trail functionality is to support the legal integrity of the health record.

Disaster Recovery: An important aspect of maintaining a legally sound health record is securing the record to prevent loss, tempering, or unauthorized use. Rules of evidence require an organization to have policies and procedures in place to protect against alterations, tempering, and loss. Organizations must

address and develop the following to adequately prepare a disaster and prevent loss or destruction of information. Data backup plan, Disaster recovery plan, Emergency mode operation plan, Testing and revision procedures, applications and data criticality analysis

Conclusion

Healthcare providers across the globe recognize the benefits of electronic health records (EHR) that provides swift, safe, improved quality and cost contained care. With these benefits, the maintenance of EHR also brings quite good number of legal challenges that need to be dealt with prudently. The legal and ethical aspects related to electronic health records needs to be understood clearly, health records must be maintained in a way that is legally sound to enable to meet the legal challenges of local, state and central /federal jurisdiction



63

Record is a permanent or long-lasting account of something, such as in writing or on film. Medical denotes pertaining to or emanating from the study or discipline of medicine. Problem oriented medical record is a standardized format for keeping clinical records in a problem-oriented case management system.

Problem-oriented medical record (POMR) is a method of recording data about the health status of a patient looking at it as a problem-solving system. The POMR preserves the data in an easily accessible way that encourages ongoing assessment and revision of the health care plan by all members of the health care team. The particular format of the system

Used varies from setting to setting, but the components of the method are similar.

A data base is collected before beginning the process of identifying the patient’s problems. The data base consists of all information available, such as that collected in an interview with the patient and family or others, that from a health assessment or physical examination of the patient, and that from various laboratory and radiologic tests. It is recommended that the data base be as complete as possible, limited only by pain or discomfort to the patient, or excessive assumed expense of the diagnostic procedure.

The interview, augmented by prior records, provides the patient’s history, including the reason for contact; an identifying statement that is a descriptive profile of the person; a family illness history; a history of the current illness; a history of past illness; an account of the patient’s current health practices; and a review of systems.

The physical examination or health assessment makes up the second major part of the data base. The extent and depth of the examination vary from setting to setting and depend on the services offered and the condition of the patient.

Problem Oriented Medical Record

Prof(Lt Col) Dayakar Thota, psc, M.B;B.S,M.Sc.,M.H.A,,F.A.G.E..

Medical Director, Ramdevrao Hospital, Kukutpalli. M : 9959000396

The next section of the POMR is the master problem list. The formulation of the problems on the list is similar to the assessment phase of the nursing process. Each problem as identified represents a conclusion or a decision resulting from examination, investigation, and analysis of the data base.

A problem is defined as anything that causes concern to the patient or to the caregiver, including physical abnormalities, psychological disturbance, and socioeconomic problems. The master problem list usually includes active, inactive, temporary, and potential problems. The list serves as an index to the rest of the record and is arranged in five columns: a chronologic list of problems, the date of each problem’s onset, the action taken, the outcome (often its resolution), and the date of the outcome.

Problems may be added, and intervention or plans for intervention may be changed; thus the status of each problem is available for the information of all members of the various professions involved in caring for the patient.

The third major section of the POMR is the initial plan, in which each separate problem is named and described, usually on the progress note in a SOAP format: S - subjective data from the patient’s point of view; O - the objective data acquired by inspection, percussion, auscultation, and palpation and from laboratory and radiologic tests; A - assessment of the problem that is an analysis of the subjective and objective data; and P - the plan, including further diagnostic work, therapy, and education or counseling.

After an initial plan for each problem is formulated and recorded, the problems are followed in the progress notes by narrative notes in the SOAP format or by flow sheets showing the significant data in a tabular manner.

A discharge summary is formulated and written, relating the overall assessment of progress during treatment and the plans for follow-up or referral.



64

The summary allows a review of all the problems initially identified and encourages continuity of care for the patient.

An early decision is made on what is the nature of the patient’s problem or problems and from then on the patient’s status with respect to each problem is assessed daily.

This has the undeniable advantage that the clinician does not lose sight of the objective with respect to the individual patient. Without this approach there is always an inclination for the clinician to attack the disease and place the patient on a lower priority.

Medical records are the detailed records, made at the time, of the clinical, clinical pathology and pathology examinations and treatments of each patient, or patient group. The records have importance to the welfare of the patient, and to potential medical research and legal investigations, and to be worth their full value they must be made contemporaneously. Medical technologist is a qualified worker in a paramedical field such as laboratory scientist, veterinary nurse or livestock inspector. Problem is a question to which there is no obvious, immediate answer; a question that requires some work done on it before a solution can be available. Problem knowledge coupler system computer-assisted diagnosis system designed for use in human medicine; based on a special matching algorithm known as pattern recognition. Problem list the list of problems to be overcome in a particular patient; in hospitals using a problem-oriented case management system. Problem name a generally accepted, preferred name for a clinical sign, syndrome or other indicant such as a positive laboratory test,

poor work or production performance or poor reproductive result.

Problem-oriented case management is a system of managing patients based on the recognition of the patient’s problems as targets for correction, planning the treatment program to achieve that and assessing performance in terms of results with each of the problems and with the case overall.

It is an excellent teaching procedure and is also helpful in maintaining the correct perspective in the patient’s program. Problem-oriented diagnosis a system of diagnosis that starts off with the cardinal sign presented by the patient and proceeds in steps to identify the body system involved, the part of the system affected the nature of the lesion and the cause of the lesion. Problem solving the basis of clinical education; learning diagnosis by practicing resolving clinical problems—the essential problem being ‘which disease is most likely to be the cause of the syndrome presented by this patient’.

PM problem-oriented medical record is a medical record in which each Patient’s condition or complaint is formally addressed; a POMR may be organized by the acronym of SOAP–subjective criteria, objective criteria, assessment plan. A medical record model designed to organize patient information by the presenting problem. The record includes the patient database, problem list, plan of care, and progress notes in an accessible format. Medical Dictionary for the Health Professions and Nursing © Farlex 2012 Copyright © 2013 Farlex, Inc. Source URL: http://medical-dictionary.thefreedictionary.com/Problem-Oriented+Medical+rec



65

IntroductionThe health industry around the world and particularly, developing counties are evolving quickly and many modern health institutions are working to advance the implementation and effective management of electronic health records (EHRs) by initiating and advocating consisted standards. Needs are evolving from simply translating data, to having access to intelligence that can drive clinical and administrative decision-making in real time. To have a right product is not that easy and most complex issue, hence one has to make efforts to ensure the product purchased or installed should not only fulfill the purpose for which it was procured but to meet the worth of the efforts and finance spent on the product.

Selection of softwareSelecting appropriate product is a herculean task and when it comes to electronic health record (EHR) systems; there are literally hundreds of products and quite good number of vendors in the market to choose one among them unless one established a well-defined comprehensive process for comparing products. The foremost, one should clear what type of product they need that would meet their requirements not only to meet for a shorter duration but also for long term. The following few tips would help in evaluation of pre-implementation EHR software that would meet and satisfy the organizational requirements.

1. First evaluate your set up, organization, size of practice, the specialty of the physicians, their typing skills and computer literacy, their attitude towards implementing EHR, infrastructure, budget and clear objective of implementing the EHR. In hospital set up, evaluate the OP, ED, and

Tips for Evaluating the Pre-Implementation of Electronic Health Records Software

Vikky (N.D. Vikram) MBA, DMRS, BMRSc, CHRIM, QMS Lead Auditor (IRCA) Prince 2, ITILDelivery Management System Sr. Advisor ERM/ESM/Revenue Cycle

Dell Services/Global Healthcare Consulting, Doha, Qatar&

Dr. G. D. Mogli, Ph.D., MBA. FHRIM (UK), FAHIMA (USA)Visiting Professor, Medical Informatics, MGM Sciences, Maharashtra, India

Ex. World Health Organization [email protected] and www.drmogli.com

IP departments including OTs, ICU, CCU, NICU, etc.

2. Determine, whether tailor made in-house software required or vendor ready-made product.

3. Clearly create the institutional or individual physicians needs. Make a clear policy to review the required products. Most important to understand all aspects of products that required including software, hardware, net work, PCs, and other equipment, storage capacity, servers, back-up mechanism, disaster plan, maintenance, vendor support, finance involved, interoperability, security, privacy and confidentiality etc.

4. Discuss the institutional policies and plans with the concerned staff of the institution and obtain their views on entire plan and improve the policy document to meet the organizational set up.

5. Examine thoroughly the product that should contain the features that you are contemplating. Another exercise with the concerned staff is to get their concurrence. Once, this is done, look for an appropriate way of acquiring that is by ‘in-house tailor made’ or ‘ready-made vendor product’.

6. If decided to have a vendor product, list in as much detail as possible every single feature you want in an ideal EHR. This should be a comprehensive and specific checklist.

7. Identify some appropriate vendors who can meet your requirements; and analyze on various aspects of issues such as economic vitality of the vendor, cost involvement, maintenance, etc. through web or communications.

8. Short list the vendor number and select a few with whom you can negotiate, get a demonstration copy of the software. A demonstration copy



66

should perform like the real product. Fully relying on a demonstration copy would be disaster, one has to have many clarification cleared before agree to enter to contract of purchase or lease whatever.

9. Make a comparative statement of your required features and the different short listed vendors. Thoroughly examine and make problem-based selection properly. Compare the products side by side to see which works best for you. By this, you should be able to decide which one is close to your needs and select those vendors and be ready to site visit, where the product is being used. Have the views of using customers in all aspects; strengths and weaknesses etc. In your visit team, there should be a well knowledgeable person who can evaluate and able to interpret the right way.

10. Finally, your experience with many vendors and lots of information should allow you to critically analyze with your team to prepare a very relevant list of questions you should ask about how well vendors respond to requests, training time, implementation difficulties, customization, upgrade frequency and specific features. How each system covers your general and specific required features? Of course, this is a sample; you will find many more issues to be tackled; it depends, on the size, type, specialty, vision and mission of the institution etc.

Expected outcome of Electronic Health Record Software:

Features of software:

Increased Productivity: Any software developed Electronic Health Records (EHR) should meet the following so as able to get maximum benefit of enormously expensive element represents patient care. While practicing management systems should be capable of increasing overall productivity to meet the expected results. The integration of EHR software should be capable to customize for enhancing office workflow, maximizing paper-based redundancies and automating the selection of diagnosis and CPT codes based on chief complaints. Any software that deals with EHR should help provider more time spent with patients and enhance the automated data for future visits, patient care plans etc.

Minimize paper records: Minimize the amount of

paper records that physician’s would keep on hand to maintain patient detailed histories and care provided. Minimize the manual work related to physician’s daily practice, automatic International Classification and Current Procedure Terminology Coding. Need laboratory reports for reviewing timely for efficient decision making. Some physicians prefer customizable EHR software besides standard one for rendering efficient patient care. The system should able to significantly eliminate transcriptions costs. Interface with other practice management, suggestive for appropriate data entry and to prevent redundant data entry.

Easy navigation: Most important functionality should be easy navigation of the menu to increase usage speed streamlining the data input process. All the software installed should be easily interface e.g. imaging systems, lab information system, and transcription etc. Identify missing information, incomplete or unsigned progress notes and other orders for correction. Obviously, the security part should permit only the authorized users, password protection and automated signature for less sensitive areas.

Single Screen: Another important aspect of consolidation of information from different sources, on a single screen, should facilitate care provider to observe his practical process much easier to complete his clinical work. The software should have internal massaging capabilities to assign tasks other staff for efficient communication.

Automated coder: Voice recognition and handwriting recognition software would be added advantage to enhance efficient and comprehensive documentation. Automated coder should capable of accurate coding and calculation of justifiable billing for service rendered. This includes ICD-10 CM and CPT codes, as well as the ability to add modifier codes and custom alternate descriptions or abbreviated descriptions. The system should capable of checking relevant information automatically and generate a bill and send to the insurance or other organization for payment.

Automatically update: As regards to encounter and admitted patient records, based on their medical histories, physical exam, the progress, additional edits are notes are automatically updated into the relevant sections of patient record. The software should have audit trails of patient data access



67

by time, date and username. The system should generate referral consultation notes, preview notes prior to completion, ability to import any other authorized information into patient record. Customize the software to automatically designate certain procedure and CPT codes for a specific diagnosis with identifying investigated lab tests and prescriptions for ordered for particular diagnosis. As well differential and complicated diagnoses are to be documented.

Side-side comparison: Precisely, the software related to patient administration should help the care provider to view side–by side comparison of patient historical vital signs, investigation reports, scanned images, voice files and transcriptions. Recall notices, scheduling, tracking of different information including patient education, consulting physicians, and any information including order tests, physician consultations and surgical procedures from the patient record; track outstanding lab and other orders, flag abnormal lab results. That has been input to be easily analyzed and produced.

Multiple prescription templates: While prescription of drugs, the system should be able to show alert drug interactions and potential drug-drug, drug-allergy and drug-pregnancy or contra-indications or conflicts. Electronically send prescriptions to specific pharmacies via a secured connection and multiple prescription templates include description of medication, dosage recommendations, patient education forms, drug ingredients, possible medication alternatives and more to assist patient care providers.

Integration of information: As regards to document management including storage and retrieval, the system should facilitate to search and retrieve easily the different images, and files could be easily indexed by patient unique number and date for faster retrieval. The system should integrate all related information including for easy document management and image scanning. Image scanned documents can be automatically indexed based on templates using optical character recognition (OCR).

Data collection support: The EHR should support the collection of data for users other than clinical care, such as billing, quality management, outcomes reporting, and public health disease surveillance and reporting. As regards to attributes, essential requirements, and evidence; provide secured,

reliable, real-time access to patient health record information, when and where it is needed to support care. For example: Essential Requirements encompass guarantee the confidentiality and security of patient health information. Information should be reliable and available at all times that care is provided; capable of integrating the care provider’s workflow, easily accessible all information related to patient’s outpatient episodes or inpatient admissions. The system should meet complete HIPAA requirements.

Permit efficient data entry: Should be able to capture and manage episodic and longitudinal electronic health record information that should include; time stamps, information source and audit trail for amendments. Permit efficient data entry of all orders and documentation by authorized clinicians including prescription writing and refill management and support electronic signature where permitted by law. Implemented EHR possess the evidence of message content standards for interoperable; such as DICOM, HL7, LOINC, Rx Norn etc.

Integration of collected data: Essential functional requirements during the patient care should include patient problem list, patent history and physical exam, progress, nursing notes, consultation notes, and patient functional status, allergies, immunizations, medications dispensed and administered, diagnostic results and images in ER, ICU, OR etc. most recent vital signs and input/output. All information collected previously for different episodic encounters, admissions, events etc. to be integrated and updated for easy reference of care providers prior to subsequent care for efficient decision making.

Assist in work planning: Assist with the work planning and delivering evidence-based care to patients: provides tools for planning and organizing the clinician’s work over a variety of time segments, such as on particular day and shift, and clinic session etc. For hospital-based care, gather data and performs checking to support regulatory and accreditation requirement such as JCAHO safe care standards, Leapfrog standards for medication error prevention. Further, it should include decision support tools to guide and critique medication administration-right patient, right drug, right dose, right time, right route.

Support continuous quality improvement: Should be able to support continuous quality improvement,



68

utilization review, risk management and performance management and provide flexible reporting tools for evaluating processes and outcomes of care by providing concurrent care, management level and on-line displays that enable easy access to summary views of pertinent information for groups (cohorts) of patients to support managers’ detection and resolution of potential quality, staffing, and risk management issues.

Capture information without error: Should able to capture the patient health-related information needed for reimbursement and billing etc without errors on claims, and should support clinical research, public health reporting, and population initiatives. This should provide disease management support for education, outreach and care to enrolled patients, support mandatory reporting, state health product liability reporting and social welfare reporting.

Summary:• Implementing an EMR system in the hospital is a

daunting task. It requires good planning, strong leadership and supportive staff.

• Organizational issues need to drive for successful EHR implementation; poor choice of technology is the first step toward an unsuccessful project. System selection should be driven by the desired outcomes, technology adoption process.

• Technology evaluation can be centered around many different components, including reliability, performance measures, standards and interoperability, customized tradeoffs, usability, and usefulness.

• An environmental analysis of the organization that includes current process and workflow assessment, readiness to adopt new technologies, belief systems, and other human factors concepts will identify the potential issues that could derail any EHR implementation.

• The pre-implementation evaluation accomplishes two things. First, it engages users in the implementation process, soliciting feedback and acting upon suggestions. Second, it can be used to identify any organizational constructs that could serve as roadblocks to successful implementation.

• Many EMRs are not designed to completely replace the paper record, so if “going paperless” is

your goal must be to ensure that the software has all the tools required to accomplish it. The most important requirement for going paperless is to have a method of scanning outside documents as text or images and filing them in the EMR.

• Decide what to scan and what not; to scan selected important documents, such as Pap smears and radiology reports, and file the rest. Once the documents are scanned, keep them for at least a week to ensure reliable computer backup, and then they can be destroyed. Some documents that do not add useful information to the record, such as the fourth chest X-ray report for a hospitalized critically ill patient, are to be destroyed.

• Training should be in three phases – initial basic skills assessment, basic skills training and application-specific training – which has to be done in three months, two months and one week, respectively, before going live. Training session to be conducted by a vendor representative and hospital trainer. A summary document outlining key work-flow changes to be distributed during the practice of training so that anyone who was unsure how to do a task with the new system had a quick reference.

Essentials for a successful EMR implementation but not limited to the following:

• Clear definition of goals,

• Strong project leadership team to run the implementation,

• Project manager with sufficient, dedicated time,

• Strong physician leader to champion the project,

• Detailed analysis of work flow,

• High level of staff flexibility,

• Commitment to “plan for the worst; hope for the best.”

Acknowledgement: I would like to take this opportunity to thank Dr. G.D. Mogli, Organizing Chairman and other members of HIM INDIA INFO-2015 for inviting me to participate and present paper in this exciting conference. And I owe my gratitude for liberally permitting me to use most of his book’s information for this article.

Reference: “Health Records Paper to Paperless”, book published in the year 2015 by Dr. G. Mogli, JAYPEE BROTHERS, Medical Publishers (P) Ltd., India. PP 440-445.



69

Standard 1 AssessmentThe nurse caring for the acutely and critically ill patient collects relevant data pertinent to the patient’s health or situation.

Measurement criteria:

• Data are collected from the patient, family, other healthcare providers, and the community, as appropriate, to develop a holistic picture of the patient’s needs.

• The priority of data collection activities is driven by the patient’s characteristics related to the immediate condition and anticipated needs.

• Pertinent and sufficient data are collected using appropriate evidence-based assessment techniques and instruments.

• Analytical models and problem-solving tools are used.

• Decisions are made by matching formal knowledge with clinical findings.

• Relevant data are documented.

• Relevant data are communicated to other healthcare providers.

Standard 2 DiagnosisThe nurse caring for the acutely and critically ill patient analyzes the assessment data in determining diagnosis and care issues.


• Diagnoses and care issues are derived from the assessment data.

• Diagnoses and care issues are validated throughout the nursing interactions with the patient, family, other healthcare providers, the community, and across the healthcare system when possible and appropriate.

• Diagnoses and care issues are prioritized and documented in a manner that facilitates prioritizing outcomes and developing or modifying the plan.

Standards of Nursing Practice in uSA

Mr. Daniel Williams, M.S Nursing (USA)Retired Nursing Director

Standard 3 Outcomes IdentificationThe nurse caring for the acutely and critically ill patient identifies outcomes for the patient or the patient’s situation. Measurement criteria:

• Outcomes are derived from actual or potential diagnoses and care issues.

• Outcomes are formulated in collaboration with the patient, family, and other healthcare providers, in relation to the level of participation in care and decision making.

• Outcomes recognize, appreciate, and incorporate differences.

• Outcomes are attainable in relation to resources available; outcomes consider associated risks, benefits, current evidence, clinical expertise, and cost.

• Outcomes provide direction for continuity of care.

• Outcomes include a target date for attainment.

• Outcomes are modified on the basis of changes in patient characteristics or evaluation of the situation.

• Outcomes are documented as measurable goals.

Standard 4 PlanningThe nurse caring for the acutely and critically ill patient develops a plan that prescribes interventions to attain outcomes. Measurement criteria:

• The plan is individualized and considers patient characteristics and the situation.

• The plan is developed collaboratively with the patient, family, and healthcare providers in a way that promotes each member’s contribution toward achieving the outcomes.

• The plan reflects current best evidence.

• The plan provides for continuity of care, matching the nurse’s competencies with the patient’s characteristics.

• The plan establishes priorities for care.



70

• The plan includes strategies for promotion and restoration of health and prevention of further illness, injury, and disease.

• The plan considers economic impact and resources available.

Standard 5 ImplementationThe nurse caring for the acutely and critically ill patient implements the plan, coordinates care delivery, and employs strategies to promote health and a safe environment.


• Interventions are delivered in a manner that minimizes complications and life-threatening situations.

• The patient and family participate in implementing the plan according to their level of participation and decision-making capabilities.

• Interventions are responsive to the uniqueness of the patient and family and create a compassionate and therapeutic environment, with the aim to promote comfort and prevent suffering.

• The implemented plan and modifications are documented.

• Collaboration to implement the plan occurs with the patient, family, healthcare providers, and the healthcare system.

• The plan facilitates learning for patients, families, nursing staff, other members of the healthcare team, and the community including but not limited to health teaching, health promotion, and disease management according to patient characteristics.

Standard 6 EvaluationThe nurse caring for the acutely and critically ill patient evaluates progress toward attaining outcomes.


• Evaluation is systematic and ongoing using evidence-based techniques and instruments.

• The team of patient, family, and healthcare providers is involved in the evaluation process as appropriate.

• Evaluation of the effectiveness of interventions toward achieving the desired outcome occurs.

• Evaluation occurs within an appropriate time frame after interventions are initiated.

• Ongoing assessment data are used to revise the diagnoses, outcomes, and plan as needed.

• Results of the evaluation are documented.

Advantages of Electronic ChartingElectronic health records (EHRs, also known as electronic medical records) have distinct advantages over paper. Mentioned most often is the not insignificant benefit that provider orders are legible and clear. Nurses no longer have to waste time consulting with one another, trying to decipher someone’s dreadful handwriting, and fewer errors related to misinterpreted orders should follow. Nurses also like being able to find information about previous episodes of care (hospitalizations or visits) easily and having all information about a patient integrated in a single place.

A Nurse said, “I love our hospital’s computer system. It is easy to use and covers all the bases. Although there is some repetition, it is getting much better, as improvements are constantly being made. I would never want to go back to paper.” Overall, most nurses who took the survey either “loved electronic charting” (45%) or reported that they “were getting used to it,” and believed they would eventually like it (26%). Although 16% were undecided as to how they felt about EHRs, only 13% reported either having a hard time with electronic charting or said they wanted to go back to paper charts.

Ward and colleagues conducted a survey of nurses to determine whether they perceived alterations in quality of patient care, clinical processes, workflow efficiency, communication, and flow of patient information after EHRs went live in a hospital setting. At 6 months after implementation, the areas that improved the most were:

• Communications when patients were readmitted or received follow-up outpatient care;

• Access to information improving the ability to make good patient care decisions;

• The timeliness with which patient-related data are available; and

• Legibility and clarity of patient care orders.

Computerized provider order entry (CPOE), implemented along with EHRs, is another feature that has the potential to improve clinician workflow, efficiency, and patient safety.



71

There is a Downside, Say NursesUnfortunately, some nurses still feel that these gains are overshadowed by the perceived disadvantages of EHRs. Even those who can see the benefits and potential of EHRs identified persisting issues that can negatively affect patient care. Although many of the problems encountered by nurses in a wide range of healthcare settings are specific to the design and functional characteristics of whichever EHR system was purchased and implemented in their work settings, other problems are more universal. These issues can be grouped into the following categories:

• Documentation time;

• “Check-box charting”;

• Point-of-care and real-time documentation; and

• Logistical and design issues.

EHRs Take Too Much TimeBefore EHRs were implemented, they were touted as a huge step forward in patient care. They were supposed to be more accurate, safer, timelier, and faster. Computers were going to free up nurses to spend more time with patients.

Instead, report many nurses, documentation is taking longer than ever. One nurse believes that since going live, EHRs have added 3 hours to a 12-hour shift. The extra time that EHRs take has many origins -- endless logging in and out; paging through unnecessary screens; duplicate entries; trying to find where to chart something; slow, cumbersome systems; and increased mandatory documentation. The latter complaint was frequent. One nurse commented that EHRs require nurses to chart not only what they did, but also what they didn’t do -- for example, “didn’t put in a Foley.” With computers in the patient rooms, nurses often can’t concentrate on the task at hand; they are constantly being interrupted by patients and visitors while they are trying to chart, and consequently, charting takes longer.

To save time, some healthcare providers take advantage of the “copy-and-paste” feature of EHRs, which might be a double-edged sword. If the person who copies and pastes does not verify every word or data point, it is alarmingly easy to perpetuate errors in the chart, a problem that many readers have already identified in actual patient EHRs.

And the time saved by CPOE in not having to write verbal orders, or interpret illegible orders, has been

lost in other ways. Some nurses report that CPOE has reduced face-to-face communication with physicians, so they have less understanding of the plan of care for patients, and they spend more time double- and triple-checking orders to make sure they don’t miss something.

The extra time that it takes to chart with EHRs must come from somewhere. Fundamentally, nurses do not consider documentation time as time spent providing patient care. Knowing that they will be judged on their documentation rather than their care, many nurses feel that patient care has suffered. One nurse even said (tongue-in-cheek), “In reality, we don’t need to do anything at all for the patient, as long as we document that we did.”

A far more common complaint is that “we are nursing the chart rather than the patient.” “I never thought I would see the day when a machine would need to be cared for more than my patient,” commented a nurse. But rarely has staffing improved to compensate for the increase in documentation time. “We have the same nurse-to-patient ratios as always, but signing in and out of a computer and documenting every little thing we do takes so much more time. That time is taken away from patient care. It’s pathetic to see us all lined up at computers instead of caring for patients!” Or lining up at computers after the shift ends. Our informal EHR survey found that in the past 6 months, 72% of respondents had stayed after their shift to finish charting (46% occasionally, 24% frequently, and 9% almost every shift). Although more than one half of respondents were paid, 21% said that they were “off the clock” when they stayed late to chart. A nurse practitioner wrote, “You have the choice of garbage in and getting out on time, or doing a decent job and working longer but uncompensated.”

Reasons given by readers for not being able to complete their charting by the end of the shift were fairly evenly divided between insufficient staffing (too many patients for each nurse), too many other responsibilities and interruptions, and unrealistic/excessive documentation requirements with EHRs. Six percent of respondents blamed computer access problems. Inefficiency or poor computer skills were cited by less than 1% of respondents, despite the fact that 55% of the respondents were older than 50 years.



72

Perception, Reality, and Learning CurvesDoes EHR documentation really take longer than paper charting? Yes, and no. In a before-and-6-months-after implementation survey, nurses reported that they were spending more time documenting patient care and less time directly with patients. In some cases, this might be a consequence of first recording data on temporary notes and then transcribing data into the computer. In earlier studies, nurses reported spending a median of 50% of their time using electronic documentation systems. Results of other studies that evaluated whether electronic documentation is more time-consuming are conflicting.

In one of the few recent studies to examine this question objectively, Yee and colleagues assessed time spent by nurses documenting on EHRs compared with paper charting. A cross-sectional analysis was completed using time-and-motion data from 105 units in 55 hospitals. They found very little difference between times spent documenting with EHRs or with paper-based charts. Nurses spent 19% of their time completing documentation, regardless of method. These findings suggest that integrated electronic medical records and computerized nursing notes do not increase the time nurses spend charting. Whether such findings are generalized to other nurses in other settings is unknown.

What is the truth? Is this a case of perception trumping reality, or haven’t we allowed sufficient time to pass for nurses to become efficient in the use of EHRs? According to our informal readers’ survey, one half of respondents have used electronic documentation longer than 3 years, and one third from 1 to 3 years.

In their observational study, Cornell and colleagues found that some nurses reported spending up to 60% of their time doing computer documentation, but these claims were not confirmed by observation. It is possible; of course, that we are more likely to hear from nurses who are having trouble adapting to EHRs or who are more concerned about the quality of documentation, and therefore spend more time on documentation than the average nurse. However, if one fourth of nurses are “frequently” staying after the end of their shift to complete charting, clearly, something is amiss.

Although nurses generally acknowledge the potential of EHRs to improve safety, many also feel

that in times of competing priorities, patient care has to come first. A nurse who designates charting as a lower priority said, “I rest easy at night knowing I didn’t sacrifice bedside care to click boxes on a screen.”

Fortunately, experience suggests that, over time, nurses become more efficient and spend less time documenting on EHRs. Willa Fields, D.N.Sc, RN, Professor of Nursing at San Diego State University, explains that mastery occurs between 4 and 8 months after the implementation of an electronic system. “With the traditional paper chart, you had a mental picture of how things worked and where they were located. You didn’t think about the time you spent flipping pages. You knew where to find things. EHRs require a new mental model that isn’t yet synthesized. It’s not actually disorganized; it’s just that you haven’t learned it yet. When you achieve that mental picture, you will zip right through it.”

Too Many Check Boxes, Too Little NarrativeWhat’s going on with the patient? The ability to read a patient’s “story” is highly valued in healthcare, not only by nurses but also by clinicians in many other disciplines.

Following the advent of EHRs, many nurses expressed dismay at the loss of space in the patient record to write narratives, to tell a story about what is happening to the patient and what occurred in the course of care. Such narratives are considered to be essential for communication between members of the team of healthcare professionals taking care of the patient. Although some like their ease of use, many nurses feel that “check boxes” and menu items don’t sufficiently capture this element of care, and that limited comment fields are inadequate.

It’s true that structured drop-down menus, a prominent feature of EHRs, are very different from paper records. But do such menus improve or detract from the quality of documentation and, by extension, the quality of patient care? Drop-down menus with panoply of choices could aid nurses by not requiring them to rely on memory for what should be assessed and documented.[6] On the other hand, picking items from a menu, rather than using critical thinking to determine what is important to a particular patient’s care, could also impair the development of those higher-level skills. Furthermore, selecting only from a menu could limit



73

the full description of the patient’s clinical status,[7] as we heard from Meds cape readers.

“I miss the freedom of being able to describe something in my own words vs. trying to put my patient in a box. Too much clicking takes the person away, and makes it too easy to overlook something or click the wrong box,” wrote a nurse. Another nurse is concerned about accuracy in check-box documentation, finding widely different assessments of the same patient by consecutive nurses who checked different boxes.

Another nurse explained why check boxes fall short when it comes to documenting unique aspects of care. “I was trained to use professional charting to document the patient’s status, what I did, and the outcome and new or continuing plan for care. All this is lost in the check boxes that now define and measure care and outcomes, and shape how we think about care. My patients are highly variable human beings. I want to document as a professional, not as a robot checking boxes. It is hard to get a good picture of the information that is there, because it is scattered over multiple screens, and it takes a long time to gather. I cannot see it all lined up together and integrated.”

But how important are narrative notes, really? Research shows that only about 38% of all healthcare provider notes, and only about 20% of nurses’ notes, are read by anyone, ever. Unless the note truly fills a gap in documentation by communicating something that does not exist elsewhere in the record, is writing notes a good use of the nurse’s time?

We heard from some people who do read EHR documentation. Here is a sampling of comments about what it is like to try to review a typical EHR:

• “It is very difficult to find needed information in the EHR. What I see is either conflicting documentation or more often, no documentation. A patient is transferred from med-Surg. to ICU and there is no documentation about the change in condition, interventions, or contact with physicians -- the patient is just suddenly in the ICU. I would hate to be the nurse trying to defend what I did for the patient prior to transfer to a higher level of care, because the EHR looks like nothing was done.”

• “Having had to do quality-of-care reviews, I can truly say that there are instances when after reading the entire record, I still cannot tell what

went on with the patient.”

• “I review charts for complaints against nurses and doctors. It is very difficult to ascertain what is happening with a patient because everything is a check-off. When patients go bad, it can be very difficult to prove or disprove that appropriate care was done at the right time. EHR charting can be a way for hospitals to omit facts.”

Another nurse who reviews charts described a nightmare of pages and pages with random numbers or words printed on them, impossible to place into context. No wonder nurses are worried about the elements of documentation that seem to have disappeared with EHRs, and their ability to defend their care on the basis of their documentation. Furthermore, many nurses are concerned that “charting by exception,” which is more prominent with the advent of EHRs, is inadequate. However, charting by exception, when supported by hospital or unit documentation policy, does meet the legal standard of care for nursing documentation.[12] So does checking off a box that says “within defined limits,” as long as these limits are defined in policy and procedure.

Still, some nurses believe that EHRs take point-click and fill-in-the-blank charting too far, making more work for the nurse. For example, a nurse complains that they now have to enter systolic, diastolic, and mean values in separate fields, which takes more time than jotting down a blood pressure. Some nurses find the descriptor choices inadequate for such items as wound assessment or pain.

The lack of prompts and free-text fields for narrative charting on EHRs is not accidental. EHRs are most useful to healthcare facilities when the data are entered into discrete fields, allowing the data to be aggregated, sorted, and manipulated.[13] Free-text data can’t be easily extracted; a manual auditor is required to search narrative fields for the desired data. If your system restricts your ability to enter comments, it is likely that this was a deliberate design feature of the EHR.

Joyce Sensmeier, MS RN, Vice President of Informatics at HIMSS (Health Information Management Systems Society), provides a perspective on this issue. “The initial wave of EHR systems included a lot of check-box approaches, replicating previous paper-based systems. Looking to the future, the next round of EHRs will optimize how we document, so it isn’t



74

just a check-box approach but focuses on telling the patient story. A pilot study has been done showing that it is possible for the EHR to pull relevant data from the history, key problems, diagnostic results, and events during the hospitalization, into a dashboard that allows providers to see the patient story at a glance when they open the record.”

The dashboard could solve the “what has happened to this patient?” problem, but what about the “what has happened during my shift?” story that many nurses used to tell through detailed narrative notes in the paper record?”

The ‘story of my shift’ is what we wrote because all we had was paper and pen, but it’s becoming irrelevant,” says Sensmeier. “No one reads those narratives. We have to get past documenting that way and move to outcomes. We need to show the impact of nursing care -- the patient improving or not being readmitted because of what the nurse does. We will always need a certain amount of free text, but we can’t use all narrative or we won’t be able to look at these outcomes.”

Changing Nurses’ Workflow: Real-Time Charting“We must remember that the EHR is a tool; it should not dictate how we practice,” wrote a Medscape reader. Perhaps it should not, but does it?

The fact is, EHRs are far more than a method of entering data -- or a digital version of the patient care flow-sheet. EHRs are sophisticated clinical information systems that extensively alter nurses’ workflow and processes of patient care.

Probably the single most significant effect on workflow prompted by EHRs is the shift to point-of-care and real-time charting. Experts in nursing documentation have always recommended that charting take place as near in time to the actual event or episode of care as practical -- nothing new there. However, a key premise of EHRs is to make patient care data immediately available to the entire healthcare team so that it is accurate and actionable. To not do so negates an important advantage of electronic documentation.

With this in mind, the fact that many nurses are staying after their shifts to chart represents a disturbing trend that should make hospitals sit up and take notice. Millions of dollars are spent to implement and maintain an EHR system -- far too

much for it to be used only as an expensive substitute for paper. So, are nurses just unable to adapt to real-time charting because it is so different, or are patient loads too heavy to permit this pattern of charting?

Nurses who commented for the charting survey were divided on this point. One nurse maintained that “A significant number of staff never learned to chart as they go and instead wait until the end of the shift to chart. Now that documentation clearly informs all of this behavior, those nurses have to incorporate what should have been ‘best practice’ all along.” Another nurse acknowledged her own difficulties with real-time charting: “It is more my long-standing personal habit of not charting in the moment that is the biggest barrier than anything else -- human behavioral change is needed.”

However, far more nurses cited workload issues, such as insufficient staffing, excessive patient loads, and unpredictable and rapidly changing clinical situations, as barriers to accomplishing real-time charting. For example: “Documenting as we go is the best, but I can’t write while my hand is pushing in a chest or restraining a drunk who wants to kill himself in the ER,” wrote a nurse.

Charting has long taken a backseat to patient care, whether it is on paper or a computer. Traditional nursing practice has often been “patients first, chart when I have time.” A 2010 study confirmed what many nurses are saying about their charting patterns, even with electronic documentation. In observations of 29 nurses, Cornell and colleagues found that nurses typically practiced “batch mode” charting, which involved accumulating patient data and later entering it on the computer. EHR implementation does not appear to be leading to the demise of the “paper brain.” Research and observations continue to find that nurses are attached to the use of informal and temporary paper notes or charting. Technology alone may not lead to “a world of real-time information.”

If nurses are unable to chart in real time because of high patient-to-nurse ratios and insufficient staffing, it makes sense to reassess workload and staffing levels, but this doesn’t appear to be happening. Many nurses feel that administrators have failed to provide the nurse staffing and support staff to match the sophistication and potential of EHRs. “As long as I have been a nurse, documentation has never been factored into the workload,” said a 30-year veteran.



75

Another said, “I need a stenographer to follow me around during my work and record everything I see, discover, think, evaluate, and do.” Still another said, “I got a nursing degree, but I’m really just a data-entry clerk. I nurse a computer instead of a patient, and it is made very clear that the computer input is more important than the patient.”

How important is it that nurses chart in real time? “Patients’ lives depend on it,” asserts Joyce Sensmeier. “Nurses are not the only ones who have that chart now -- everyone has it, and they all depend on it for up-to-the-minute information. We can’t wait to chart anymore.”

Point-of-Care ChartingHand-in-hand with real-time charting is point-of-care documentation, representing another change in nurses’ workflow ushered in by EHRs. The idea is that computer workstations would be located in patient rooms or wherever care is provided, enabling nurses to document care as it is delivered. An inability to incorporate point-of-care documentation into nursing practice can threaten successful implementation of EHRs.[15]

In the past, nurses might document vital signs, intake and output, and other data on flow-sheets or scraps of paper at the point-of-care, but the bulk of documentation took place in centralized locations, such as nurse’s stations, or cubbyholes located outside of patient rooms. EHR documentation has brought computers to the bedside and into the examination room. Charting in the patient’s room, however, has raised concerns.

Angie Kohle-Ersher is an information technology nurse who recently conducted a study that contained 2 surveys. The first survey, which asked nurses about impediments to point-of-care documentation, identified the following barriers:

• Location of the computers in the room. Nurses had to ask visitors to move, turn their backs on patients while charting, or chart standing up.

• Unreliability of computers in patient rooms -- they are slower, and often freeze up.

• Privacy concerns: visitors looking over the nurse’s shoulder, reading the chart.

• Some patients dislike the nurse charting in room; patients interrupt with questions and requests.

• Some patients complained that the lights emitted from computer monitors disrupted their sleep.

Kohle-Ersher’s findings are supported by other research has well as the anecdotal experiences shared by Medscape readers.

A self-described “mature nurse” dislikes charting while talking to patients. “I like to give the patient my full attention, with good eye contact. This is very important for assessing the patient as a whole. A lot is missed when nurses (and doctors) stand at the computer and just go down the list, barking out questions to fill in the boxes.” Another nurse concurs. “Some providers don’t even make eye contact with a patient because they are focused on the computer. It takes some of good bedside manner away from the encounter.”

Kohle-Ersher has heard these concerns before. “Although point-of-care charting -- when done properly, where care is delivered -- is more accurate and improves timeliness of care, nurses don’t yet see the value enough to change their workflow habits to accommodate it. In the study, we found that having in-room computers has not changed the location of charting. Sometimes the in-room computers don’t work as well as centralized computers. It takes longer to boot up and log on to them. Some patients will even complain about the lights of the computers when used at night in the patient rooms.”

Kohle-Ersher’s second survey asked nurses to rate the priority of everyday nursing tasks. In most cases, documentation was rated at the lowest priority of all nursing tasks. This finding suggested to Kohle-Ersher that nurses did not view point-of-care documentation as a high priority and that it did not influence the timeliness of care, which she says is a false conclusion. “Documentation does affect the timeliness of care. When a nurse is ready to give a pre-meal insulin dose but has to track down the nursing assistant first to find the patient’s glucose level, care is compromised.”

One proposed solution to this problem is computers on wheels/workstations on wheels (COWs/WOWs), although these can be difficult to maneuver in crowded patient rooms. With COWs/WOWs, the nurse is able to coordinate with the patient’s care plan and incorporate nursing interventions and assessments from the EHR, and collect data from the patient, all at the bedside instead of going to a computer at the nurse’s station. Used in this way, the COW/WOW allows the EHR to adapt to, rather than disrupt, the nurses’ workflow.”Anecdotally,”



76

says Kohle-Ersher, “nurses have responded well to WOWs, but we don’t know whether their use has actually increased point-of-care charting.”

Luann Whittenburg, PhD, RN, Chief Nursing Informatics Officer at Medicomp Systems, agrees that point-of-care charting can be difficult to accomplish. “Sometimes the EHR doesn’t encourage the close proximity needed for event charting. We know that nurses are not in control of how the day flows, so we need to give them flexibility to chart at or near the point of care. Some facilities are going to mobile devices, so there is a greater probability of real-time/point-of-care charting.”

Whose Chart Is It, Anyway?“The purpose of an EHR should be helping the end users (us) to be more efficient in charting and free up time for direct patient care,” observed a Medscape reader. However, this nurse reflected, “this has not been the case.”

It is no wonder that many nurses feel that they have turned into data-entry clerks. Most nurses are strictly on the “input” end of EHRs, and have little or no experience with the output. It is difficult to appreciate the value of the tremendous amount of information that is processed when all one does is endlessly enter data, especially if the data being entered don’t truly reflect what nurses do -- in other words, nursing practice. “Systems seem to be built for the collection of quality improvement data, meaningful use, and physician order entry, not for the ease of nursing documentation,” commented a nurse. Another wrote (and others echoed the sentiment), “Charting is about money, accounting, inventory, reports, and many tasks that have nothing to do with nursing.”

All of this begs the question: Do nurses and hospitals have different priorities when it comes to documentation, and how can they be brought together?

Traditionally, the purpose of nursing documentation is to facilitate information flow that supports the continuity, quality, and safety of patient care. Over time, documentation has accumulated many other purposes. Even with paper charts, new forms were added from time to time to meet some regulatory requirement or other. Now, EHRs have made it even easier for administrators, payers, reviewers, and government agencies to add required fields to the

EHR so that they can track data, overloading the nurse with documentation requirements.

“Many of the documentation requirements that are considered excessive by nurses were put into EHRs to meet Joint Commission standards for core measures (E.g., stroke, acute myocardial infarction, and venous thromboembolism) and to meet quality care measures for CMS [Centers for Medicare & Medicaid Services]. As CMS reimbursement shifts from volume to outcomes-based reimbursement (value-based purchasing programs), nurses can expect to see more required documentation,” explains Angie Kohle-Ersher.

Willa Fields acknowledges that the burden of nursing documentation, whether on paper or computer, has increased over time. She disagrees, however, that such requirements are unrelated to patient care, and believes that nurses need to broaden their view of what they do, reminding them of the tremendous value of their documentation to all patient care. “Patient care is more than what we provide to individual patients,” says Fields. “The information that nurses document can be analyzed to identify opportunities for improvement both for individual patients and the population at large.”

Luann Whitten burg believes that we need to bring the nursing process back to nursing documentation. Current EHRs, she says, this by providing nurses with a single note space that is customizable for each organization and works with other components in a nursing have disconnected the nursing assessment from the nursing process that supports nursing care decisions: nursing diagnoses, planning, interventions, and outcomes.[19] “The future for the EHR involves expanding the capture of coded nursing data using a nursing language that follows the nursing process for patient care. Nurses can then begin to tell a cohesive and accurate electronic patient story in an EHR.” At Med-comp, Whittenburg is currently testing a system that will accomplish documentation tool.

From user-unfriendly to Nurses’ Best FriendIt was clear from the comments made by nurses that many different EHR systems are in use today, explaining the high degree of variability in functionality and user-friendliness reported by nurses. Some nurses complained of redundancy in required documentation, poor or non-intuitive organization of screens, difficulty locating where



77

to enter data, and other system-specific issues. Sluggish system operation was a frequent complaint -- slow log-on and loading of screens (possibly related to high demand), screens freezing in the middle of documentation, loss of data (requiring the nurse to start over), and system downtime (requiring reverting to paper documentation) were sources of frustration with some EHRs. Some nurses complained of frequent system changes and upgrades, and a lack of information technology support when needed.

At the same time, we heard many variations on the theme of “electronic records are here to stay,” such as this: “Electronic charting benefits the patient and streamlines their care. Nurses need to get on board and be the advocates that support this change.” A nurse who moved back into a setting with paper charting “realized just how much of an advantage even an imperfect EHR was” over paper. Another said, “Anyone who wants to return to paper either hasn’t given EHRs a real chance or can’t remember the problems with paper -- thumbing through charts to find what you need, requesting old charts, finding the last space for a note taken and having to restock the chart before continuing, lugging charts up and down the halls....”

Still, even nurses who favor EHRs over paper acknowledge that EHRs need to evolve, and there is much room for improvement. “I love the potential for the EHR,” said a reader, “but currently so little is done to pull the power of computers into actual practice.” For example, many systems don’t dump data from monitors and screening devices into the EHR in real time, a function that could be a significant time-saver for nurses. Joyce Sensmeier has encouraging news. “Device data that automatically populate the EHR is where we are heading.”

Nurses value many aspects of EHRs, but usability is not yet where it needs to be. Nurses want an EHR that supports their work with integrated patient information, and helps them provide efficient, safe, quality care. Willa Fields agrees that EHRs aren’t as user-friendly as we need them to be. “We have not solved the interoperability and usability issues of EHRs,” says Fields. “The EHR must complement and improve the nurse’s work, rather than impede it.” Fields encourages bedside nurses to seize the opportunity to be part of the design team when systems are selected, configured, or upgraded. Her research shows that nurses also need education not only on the technical aspects of EHRs, but also on anticipating and managing the inevitable changes to nursing workload, workflow processes, and patterns of communication with physicians and other healthcare team members.

Along these lines, Sensmeier emphasizes that “every organization needs nurses with competence in informatics so that EHR systems are configured the right way, and are helpful and meaningful,” and that “chief nursing officers must advocate for what is needed to make these systems right for nurses.”

How close are we to the solving the problems identified by nurses, and what does the future promise? Sensmeier responds, “We are making good strides. In another 5 years, we will be in a really good place. We will see major improvements, and will be able to look at outcomes. Moreover, the entire system will be less one-way -- it will become more interactive. It will actually give information back to the nurse in the form of clinical decision support. On the basis of intelligence (patient data entered by the nurse), the EHR will give the nurse evidence-based suggestions for nursing interventions -- a patient-specific, best-practice resource for the nurse to use.”



78

Medical Records Documentation:Medical Records are legal records that must be maintained in a very careful and legal manner. They must also be used in a legal way. They:

• Tell us and all the other members of the health care team about the patient, his/her care and treatments;

• Tell us facts about the patient or resident;

• Help people, like the doctor and nurse, to make good decisions about the patient and his/her care; and

• Help us to find out how well the care that is being given is helping the patient.

Documentation in these records must be:

• Complete

• Correct

• Timely

• Legal

• Professional.

Hospitals use many kinds of forms and ways to document the care the patient is given. Daily care and hygiene in some places is written on a flow sheet form. In other places this care is written in a progress note or entered into a computer. Most hospitals are now using computers and eliminating paper documentation format.

Complete DocumentationDocumentation must be complete. You must record everything that you DO and everything that you OBSERVE. All care and all treatments must be recorded. You must record everything that is observed; things that you see, feel and hear, especially of they are not normal/or not normal for the patient that you are taking care of. “If you didn’t document it, you didn’t do it”. These findings

Doctors and Nurses Records Documentation

Mr. Y. EBEN JEYA ROY, M.A., B.Ed., B.M.R.Sc.,Medical Records Supervisor,

Medical Records Department,JIPMER Hospital,

Puducherry-605006.Mobile No. +91 9442545565

E-mail: [email protected]

should be reported immediately and recorded in the persons medical records.

Things that may be included are:

• Baths

• Showers

• Oral care

• Denture care

• Foot care

• Hair and nail care

• Urinary catheter care

• Back care

• Turning and positioning

• Meal intake

• Fluid intake

• Activities, like walking

• Range of motion exercises, if done

• Warm soaks

• Cold applications

• Levels of consciousness

• Orientation to time, place and person

• Height

• Weight

• Urinary drainage bag output

• Temperature

• Pulse

• Respiration rate

• Blood pressure

• Blood glucose readings

• Color of the skim

• Warmth and characteristics of skin (wet, dry etc)

• Things that the patient or resident says

• Things that the patient communicates non-verbally, such as frowning which means anger or pain



79

• Behaviors such as anger, crying and yelling, and

• Talks that involved the nurse, patient, Doctor, and/or family member.

Correct DocumentationAll of the documentation in the patients chart must be correct. If a person’s temperature was 101.4 degrees at 2.20pm, the reading and the time that it was taken should be recorded exactly. It should NOT be written that the temperature was 101 degrees taken at 2pm. It must be recorded exactly as it was taken. It is also important to document the things that you actually see. For example, you should not write that the “patient was lazy today”. This may not be true. You do not see “lazy”. You may have thought the patient was lazy but you did not see or hear lazy. It may not mean that a patient is lazy when you see them sleep most of the day. The patient could be sleepy due to their illness or may not have slept well due to their pain and discomfort. Instead, you should write what was actually observed, “The patient slept from 8am until 12pm and only woke up when their vital signs were taken at 10am”.

Timely DocumentationDocumentation must be competed timely. This is because the documentation is used to communicate about the patient. It must ready to see and be used to make decisions. DO NOT wait until the end of a shift to complete documentation. It is a vital part of patient care and needs to be completed timely. If documentation is not completed appropriately and timely, it is difficult to determine if symptoms have improved or worsened over time. Any sudden change in behavior would not have been noted, documented and therefore NOT communicated to the Doctor. This may prevent necessary medications or other treatments being administered to the patient in a timely manner. Timely reporting and documentation can prevent serious injuries and further complications.

• Always record and orally report any finding that DO NOT seem normal

• Immediately report and document any sudden changes in behavior

• Always record your findings in a complete and precise manner

• Never wait until the end of a shift to report finding and observations or to complete documentation

Legal DocumentationMedical records are legal documents. They must be used and stored according to all governing laws and also to the policies of the hospital. In order to treat these records as legal documents:

• Use blue or black ink unless you are using a computer or your hospital uses a special ink color for different shifts;

• Do NOT use pencil or ink that can be erased; Write so that it can be read clearly, sloppy writing causes errors; Date all of your notes; Write the time that you took your notes; Sign your full name and title (RN, LPN etc); Do not scribble out things if you make a mistake; Do not use white out or any other cover up for mistakes;

• Write only the facts; be professional and never add personal comments or feelings; Do not chart before the facts. Follow the flow sheets according to the next incremental step; Do not use abbreviation unless they are accepted for use by your hospital; Do not allow anyone to touch or look at your medical records unless they are a healthcare worker assigned to take care of the patient; Keep all medical records in a safe and secure place;

• Medical records are confidential. Do not disclose or discuss any facts of the patient or their care with anyone other than the assigned healthcare staff or the patient themselves.

SummaryMedical records, whether computer or paper based, hold very important information about the patient’s health and medical condition. This information is not only vital to their medical treatment but is also highly confidential and private. This information CANNOT legally be shared with anyone other than the assigned medical staff and the actual patient. All records must be completed accurately, completely, timely, legally and in a professional manner.

Thanking you,

Y. EBEN JEYA ROY,Medical Records Supervisor,Medical Records Department,JIPMER, Puducherry.



80

IntroductionHealth Information Management (HIM) is the practice of acquiring, analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper based) records are being replaced with Electronic Health Records.

The tools of health informatics and health information technology are being increasingly utilized to introduce efficiency in information management practices in health care sector. Hospital information system is common implementation of Hospital Information Management.

Health information management professionals plan information system, develop health policy and identify current and future information needs. In addition they may apply the science of informatics to the collection, storage, analysis, use, and transmission of information to meet legal, professional, and administrative records keeping requirements of healthcare delivery. They work with clinical, epidemiological, demographic, financial and coded healthcare data.

Drug safety, medical mistakes, healthcare acquired conditions, information system constraints are just some of issues affecting healthcare quality and safety. Addressing these challenges requires organizations capture valid and reliable data that can be transformed into usable information to aid in developing change strategies.

use of Health Care DataSeveral reports outlining the quality and safety issues that are negatively affect the healthcare system. Health organizations must capture information that supports a more accurate measurement of healthcare quality, such as determining how adverse events actually occur in hospitals.

Existing data from laboratory, clinical registry, and electronic health record systems can provide the necessary information to improve patient safety and quality. Effective HIM practices facilitates the

Health Information Management and Patient Safety

D. M. JOSEPHSt. John’s Medical College Hospital, Bangalore

aggregation of data from multiples sources to enable the capture of data and it can be repurposed many times.

HIM and IT must collaborate to manage the increasing volumes of electronic data. HIM professionals must be an active participants in the entire HER lifecycle. The professionals have to leveraging their knowledge and expertise in records management, confidentiality and security, workflow, terminology and classification systems, and health information exchange.

The expansion of IT and electronic documentation is improving the capture and quality of healthcare data and more reliable care delivery system. In order to continue advancements in these areas, organizations must facilitate the flow of information among different parties. Leveraging electronic data from numerous sources and integrating it into a centralized repository can help improve the quality and consistency of patient care delivery. Him ‘S Role in Quality and Safety InitiativesAchieving for quality goals requires improved documentation throughout the healthcare system. The age old adage “If it is not documented, it was not done” is as appropriate as ever. The responsibility lays with HIM professionals to monitor the quality of documentation while working collaboratively with other members of the health care team to maintain the clinical accuracy and completeness of the data. These efforts will be the key to identifying system and process problems within the realm patient safety and quality of care.

While the ultimate goal is delivering safe and improved patient care, it cannot be ignored that errors made during hospitalization result in greater costs, (increased length of stay, additional procedures) Patient safety and compliance issues a major factor in data integration. Though the use of clinical decision support and electronic documentation , healthcare associated infections , falls, and other negative healthcare associated events can be more quickly identified, tracked monitored and eliminated.,



81

HIM professionals are ideal candidates to lead patient safety and quality improvement initiative while at the same time playing a pivotal role in the information capturing process and system improvement measures. Patient safety initiative requires all forms and types of data capture, many of which are already managed by HIM in paper and electronic formats.

For example:HIM professionals are able to provide data related to serious adverse events, present on admission indicators, and hospital acquired conditions. They are equipped to analyze and interpret these data and participate in the patient safety teams that conduct root cause analyses and develop action plans for improvement. Evolving Data SpecificationAs data and classification system evolve, HIM professionals will be available to ensuring the appropriate interpretation and conversion of healthcare data related to many uses, including

patient data, organizational effectiveness and efficiency and policy making and reimbursement system.

For example: Implementation of ICID10 and other terminology system such as SNOMED CT will necessitate a better understanding of how data are collected, analyzed, and reported to ensure information is understandable and useable.

HIM professionals make a difference by advancing the effective use of personal health records or patient portals and serving as a health information advocate on behalf of patients. Consumer access to health information can greatly enhance safety, facilitate patient engagement and improve continuity of care.

Conclusion Leveraging HIM professional’s expertise as a key partner in a multidisciplinary patient care team enables effective management and use of healthcare information to further advance improvement in quality and patient safety systems.



82

Private Hospitals are known to spend 40-50% and Govt. Sector >70% of their budget on Human Resource alone. Quality in Healthcare is much more than conformance to standards, the ultimate Goal of quality in Healthcare is “Zero Error”. In spite of this, Hospitals in general do not give much credence to the importance of preventing common mistakes committed by their staff by holding them accountable. In fact, the management indulges in brushing them under the carpet and the matter is closed with a verbal warning.

In this presentation, a simple solution to discipline the hospital staff smoothly is suggested which is seamless and without any fuss. What is required is a good computer network in the hospital with suitable program. Critical job responsibilities of the staff are identified for each category and a checklist is prepared based on individual category’s job responsibilities. This checklist is provided in a format online which is completed by the staff member before leaving the place of duty. The defaults are controlled by linking it to the attendance swiping. This has been tested and tried in a super specialty hospital without any fuss or protests.

“An Innovative Approach To Hospital Staff Accountability”

Prof P Satyanarayana



83

Dr. P. SatyanarayanaMBBS (OSM), MHA (AIIMS), FIAMS

Mobile: 09866337675Email: [email protected]



84

In India you have been working through traditional manual MEDICAL RECORD MAINTAINANCE.

Bundling the inpatients records, preserving by way in dumping area is the practice of some hospitals. Less staff, shortage of space, shortage of stationary is common problems we all facing. Due to MCI’s implementations the present scenario changing little bit. All the hospitals digitalizing the Medical records partially due to shortage of budget in government sector hospitals. Some private hospitals already implemented EMR/HIS/HIM….. Etc. means they digitalized the medical record system, but not yet PAPERLESS due to non-acceptance by the law.

Any how, the scenario changing from manual to digital. But in international level, the scenario is totally different from India.

Cloud Based Medical Records Servers, Accessing through PALMTOPS/ TABLETS/ SMARTPHONES

The technology is implementing lots of inventions. The patient can preserve his personal medical records with cloud based medical records preserved in international servers, and without carrying any physical documents he and his doctor can go through patients previous history with a click access.

Hospitals can access EMR/HIS/HIM….. Etc services, services through net.

Doctors can schedule appointments; can maintain their own patient’s records.

Does Medical Record Staff Exist in Future?By glancing at technological development we can definitely say that there is no future MR Professionals unless they become EMR/HIS/HIM professional or Coders. Otherwise they will be procedural physical maintenance experts of Medical records.

Coder’s profession snatching the important role of Medical records professionals.

Medical Records Present and Future Scenorio

Vijay kumar M. K.MRO trained by CBHI DGHS

Medical records officer.Mysore medical college and research institute, Mysore.

Now a days CODING is a boom in out sourcing health care speciality. There’s heavy demand for coders in India. During 2016 more than 20000 coders needed for this industry. The coding trainer’s business companies are training all paramedics as coders including Doctors. The coding also became so complex and speciality wise coding suggestive.CPC, CPC-H, CPC-P, CCS, CCA, RMC, CMBS, CMRS, CCATetc., are specialties still we don’t know the expansion form of those and the codes we never seen. To understand those we have to be trained.

I suggest: this is right time to keep on eye on developments in this field and take right decission.

Let’s see what Dr. David Blumenthal express about future.

The Future of Health Care and Electronic Records

Today, we’ve taken great steps forward in bringing America’s health records into the 21st century. Widespread and meaningful use of fully functional electronic health record systems combined with a robust infrastructure for broad-based health information exchange can improve the quality, safety, and efficiency of health care for all Americans.

As more organizations adopt electronic health records, physicians will have greater access to patient information, allowing faster and more accurate diagnoses. Complete patient data helps ensure the best possible care.

Patients too will have access to their own information and will have the choice to it with family members securely, over the Internet, to better coordinate care for themselves and their loved ones.

Digital medical records make it possible to improve quality of patient care in numerous ways. For example, doctors can make better clinical decisions with ready access to full medical histories for their patients—including new patients, returning patients, or patients who see several different providers. Laboratory tests or x-rays downloaded and stored



85

in the patient’s electronic health record make it easier to track results. Automatic alerts built into the systems direct attention to possible drug interactions or warning signs of serious health conditions. E-prescribing lets doctors send prescriptions electronically to the pharmacy, so medications can be ready and waiting for the patient.

And while electronic health records require an initial investment of time and, clinicians who have implemented them have reported saving money in the long term. With the efficiencies that electronic health records promise, their widespread use has the potential to result in significant cost savings across our health care system.

The future looks bright, but the vision can’t become reality without first laying a firm foundation.

Helping us in this endeavour are the providers, software developers, health care administrators, patients, and others on the frontlines of health care. We talked with them about their experiences and

expectations of health IT. We heard their aspirations and their reservations. Our commitment to ensure privacy and security of electronic health records and health information exchange will remain at the forefront of all our efforts. will lead to the development of a structure designed to support and improve health care.

Vijay kumar M. K.MRO trained by CBHI DGHS

Medical records officer.Mysore medical college and research institute,

Mysore.



86

Introduction:The requirements for the functionality of the Electronic Health Record will vary and must function under ethical and legal principles specific to the time and place. Different countries may have diverging functional requirements for the content or usage of electronic health records, which can require radical changes of the technical makeup of the EHR implementation.

Health Level Seven, Inc. (HL7) defined the first EHR functional requirement standard in February 2007. The standard outlines important features and functions that should be contained in an EHR system. The standard’s Functional Model contains approximately 1,000 conformance criteria across 130 functions, including medication history, problem lists, orders, clinical decision support, and those supporting privacy and security. The function list is described from a user perspective and enables consistent expression of EHR system functionality, while the conformance criteria serves as a reference for purchasers of EHR systems and vendors developing EHR software.

The EHR standard functional model has proven to be a powerful tool for the Certification Commission for Health Information Technology (CCHIT). The HL7 standard for EHR systems has been extremely valuable for CCHIT’s development of certification criteria.

EHR Functional RequirementsMany of the requirements of an EHR are identified based on a fundamental functional understanding of what an EHR is intended to achieve, whether implemented as a middleware service or as a sub-component of a healthcare information system. The EHR must enable the communication of healthcare information to support shared patient care, improved quality of care, and effective resource utilization. This includes the support of evidence-based care and the rich ability to navigate and analyze EMRs for a wide range of purposes. Users must be able to access health record information from whichever system and in whatever format it is originally stored.

E.H.R Functional Requirements Specifications

A. Balasubramanian, M.A., B.M.R.Sc., AHRIM (UK)

The functional requirements are classified as shown:

• Administration requirements

• Clinical documentation requirements

• Data export requirements

• Data import requirements

• Clinical decision support systems requirements

• E Prescribing requirements

• Orders management requirements

• Reporting requirements

• Results management requirements

• Privacy protection and security requirements

Administration Requirements: The clinical basis for this requirement is to provide comprehensive benefit eligibility (health plan, Medicaid, Medicare, etc.) information, to include managed care information. EHR will have the ability to conduct eligibility checking for all commercial health plans and Medicaid from within the application.

The functional requirement is that the EHR system can verify and document patient eligibility (e.g. insurance information) and patient demographic information. The system shall allow appropriate clinical staff to document and/or update patient identifying and financial information, and verify insurance eligibility. The system can print out medical summary including medication and diagnosis list.

B. Clinical Documentation RequirementsThe clinical basis for this requirement is the clinical staff can document patient medication history electronically from patient. Clinician shall confirm previous medications and prescribe any potential new medications or make dose changes. Clinician shall come up with treatment plan and creates any new orders. Clinician shall have the ability to create treatment plans and create and electronically submit orders such as labs, radiology, physical therapy, and other supportive services. Specialist can document consult note, recommendations, and clearance. New medications or changes are ordered.

The functional requirement is that the EHR will have the ability to perform basic clinical documentation,



87

including medication history. Current, active medications are viewable on demand. The system shall have the ability to display a complete medication history from information available within the EHR. The system can document a consultant note with appropriate clinical information from the medical record, recommendation, and clearance.

C. Data Export RequirementsThe clinical basis for this requirement is that the provider will receive through their IT system, a complete and accurate medication history from multiple data sources in a single-view. The medical history shall include the following in a clinically usable format: differences between acute/chronic medication, sample history, different drug programs, medication reconciliation, and medication renewal history/compliance. Medication Compliance includes drug name, dose, route, duration, prescribers name, area of prescription, prescription order date, prescription filled date, other chronic medications and so on.

The functional requirement is that the EHR will capture and export data elements required for defined medication reconciliation. Ambulatory EHR can export required medication reconciliation data elements, according to local standards and sharing rules. The system shall have the ability to capture patient medication and dispense history electronically from available electronic sources and render information to clinical user in a single view. This data should also be available for data export. It is strongly encouraged that EHR’s immediately develop capability to export and import structured medical summary data, including medication histories.

D. Data Import RequirementsThe clinical basis for this requirement is that the physician shall receive email alerts/messages directing her/him to a Care Consideration regarding one of her/his patients. A Patient Health Record (PHR) system uses Clinical Decision Support Systems (CDSS) to create a set of Care Considerations for a patient. An alert can be sent either to the Health Insurance Exception (HIE) or directly to the EHR that contains a link to the PHR for the provider to view the CC document.

The functional requirement is that the EHR shall import alerts from the HIE as per standards determined by the Regional Health Information

Organization (RHIO). The EHR is able to retrieve (manual or automatic) aggregate clinical data to review. The system shall have the ability to incorporate data from another remote system’s assessment tool data. It is strongly encouraged that EHR’s immediately have capability to export and import structured medical summary data.

E. Decision Support System RequirementsThe clinical basis for this requirement is the quality measurement. The system shall allow for frequent updates to the list of required data elements and numerator / denominator / exclusion statements for each measure. The system shall populate the EHR so that when a patient history of applicable life habit (nutrition, obesity, alcohol consumption, smoking, etc.) is documented, the indicator to advise the patient to stop behavior is automatic and there is a standard field with structured nomenclature for the documentation of advice.

The functional requirement is that the EHR system will allow additional required data elements to be added to the system based on enhancements to measures. The system shall populate the EHR so that when a patient history of applicable life habit is documented, the indicator to advise the patient to stop behavior is automatic and there is a standard field with structured nomenclature for the documentation of advice.

F. ePrescribing RequirementsThe clinical basis for this requirement is that the system shall have decision support capabilities. Technology allows cardiologist to determine if prescription drug is on formulary of patient’s insurance plan. Formulary information provided through EMR or passed through the HIE by the RHIO. The system shall have decision support capabilities around medication alerts. The system shall be capable of allowing Emergency Department (ED) physician to verify known patient allergies prior to completion of ED prescription.

The functional requirement is that the EHR has Rx decision support for drug-drug interactions and allergy checking and has mandatory alerting for drug-drug interactions, allergies in the eRX process. The system shall have the ability to alert the provider to medication contraindications. The system shall support eRX capability according to standard protocols, and drug-allergy and drug interaction



88

checking, with real-time feedback to ordering clinician. The system shall be capable of allowing a physician to verify known patient allergies prior to completion of a prescription.

G. Order Management RequirementsThe clinical basis for this requirement is that the system must capture and track the referral and track that the appointment was kept, results reviewed and sent to Primary Care Physician (PCP) and that the PCP has communicated with the patient, and where available include reasons for lack of completion. The EHR shall allow for electronic referrals and be accessible through the HIE. Vendor would maintain referring physician table with phone numbers. Clinician shall confirm previous medications and prescribe any potential new medications or make dose changes. Clinician shall come up with treatment plan and creates any new orders. Clinician shall have the ability to electronically submit orders such as labs, radiology, physical therapy, and other supportive services.

The functional requirement is that the system must capture and track the referral and track that the appointment was kept, results reviewed and sent to PCP and that the PCP has communicated with the patient, and where available include reasons for lack of completion. The EHR shall allow for electronic referrals and be accessible through the HIE. Vendor would maintain referring physician table with phone numbers. If electronic ordering is not live, system can create customized order forms for e-fax to relevant facility.

H. Reporting RequirementsThe clinical basis for this requirement is that the system shall have the capability to automatically identify patients who meet denominator requirements of each quality measure. Quality measures are still to be determined by projects. The system shall have the capability for the provider to manually select/deselect a patient as part of a panel of patients who are relevant/not relevant and qualified/not qualified for specific quality measures.

The functional requirement is that the system shall have the capability to automatically identify patients who meet denominator requirements of each quality measure. The system shall have the capability for the provider to manually select/deselect a patient as part of a panel of patients who are relevant/

not relevant and qualified/not qualified for specific quality measures. Panel can be selected using ad hoc or embedded reporting functionality.

I. Result Management RequirementsThe clinical basis for this requirement is that the system shall send the lab request electronically. Lab results are populated electronically into the EHR with flags for abnormal results; reminder is set in EHR for recommended time frame for next lab test. All lab vendors must provide compendium with mapping to Logical Observation Identifiers, Names, and Codes (LOINC), and must send LOINC mappings as determined by the RHIO.

The functional requirement is that the lab results are populated (imported) electronically into the EHR with flags for abnormal results. The EHR must accept electronically delivered lab results. The EHR must accept LOINC-mapped electronic lab results if available from the source lab.

J. Privacy and Security RequirementsThe policy basis for this requirement is: in the event that a RHIO becomes aware of any actual or suspected privacy and/or security breach, either through notification by a participant or otherwise, the RHIO shall immediately investigate (or cause the applicable participant to investigate) the scope and magnitude of such actual or suspected breach, and promptly identify the root cause of the breach. Physician practices have a parallel requirement to investigate the scope, magnitude, and root causes of suspected breaches. In the event of a privacy and/or security breach, the RHIO shall mitigate (or cause the applicable participant to mitigate) to the extent practicable, any harmful effect of such privacy and/or security breach that is known to the RHIO or the Participant.

The functional requirement is that the system must permit a person with administrative access to log into the system to investigate a potential breach. The system must have ad hoc query capability to assist in investigating potential breaches. The system must allow an administrator to terminate all users’ access to a specific patient’s data, or discontinue a user’s access to the system in the event of a breach. The system must be able to determine when an “access” has occurred and log that event, in order to take corrective action, comply with State notification requirements and potentially inform patients of



89

breach of their information.

Functional Requirements vs. Technology

The technologies often included within requirements are difficult to generalize to any potential EHR implementation as they are often expressed in terms of the technology envisaged by the authoring project or team. However, there are a small number of themes that are probably generalizable to any kind of implementation, and are mentioned for completeness. A specification for the information model of an EHR would probably not explicitly demonstrate conformance in the areas listed below:

• Information models for messages

• Conformance to international standards

• Record server and persistence, interfaces and services

• Performance and concurrent use

• Version control

• Exceptions and errors

Ref. “Health Records Paper to Paperless” By Dr. G. D. Mogli, JP Brothers Medical Publisher Pvt.ltd.



90

Introduction:Maintenance of records: All medical records including patient files, registers, index cards etc., relating directly to the patient care, must be maintained by the Medical Record Department. The Medical Record Department should collect the old registers and files from all of the wards, the emergency department, the outpatient clinics, etc. and then classify them properly by the old record register number. The old files, registers, and index cards should be preserved in a designated place for a prescribed period. Later, the records may be destroyed in accordance with the regulations established for record retention. If you are using computers, then the same to be stored properly classified for easy accessibility. The information stored to be secured and confidentiality to be maintained.

Retention of records: As a result medical legal issues, continuity of patient care, medical education and research coupled with lack of space for the filing of medical records, a retention schedule for keeping records has to be prepared for the guidance of the hospitals. However, those hospitals which are carrying out teaching or research programs may keep their records longer than the prescribed period provided they have adequate space and facilities.

Preservation of records: Special care must be taken to preserve medical records. Patient records must protect from insects and termites, and protected from exposure to hot and dry climates. They should be filed in a dust free environment and protected from water, dampness, and fire. Adequate fire extinguishers should be available at all required places. Medical records can be retained as original hard copies, or can be microfilmed and digitalized records in computers.

Medical Council of India Guidelines on Medical Records:The issue of medical record keeping has been addressed in the Medical Council of India Regulations

Retention and Preservation of Medical Records - Paper and Paperless

Dr. G. D. Mogli, Ph.D., MBA., FHRIM (UK), FAHIMA (USA)Visiting Professor, Medical Informatics, MGM Sciences, Maharashtra, India

Former World Health Organization [email protected] and www.drmogli.com

2002 guidelines answering many questions regarding medical records. The important issues that have been addressed are as follows:

1. Maintain indoor records in a standard prescribed form for 3 years from commencement of treatment (Section 1.3.1 and Appendix 3).

2. Request for medical records by patient or authorized attendant should be acknowledged and documents issued within 72 hours (Section 1.3.2).

3. Maintain a register of certificates with the full details of medical certificates issued with at least one identification mark of the patient and his signature (Section 1.3.3).

4. Efforts should be made to computerize medical records for quick retrieval (Section 1.3.4).



91

Medical Record Retention Schedule

Name of Medical Record Retention in original

from (in years)

Effective from the date Permanent retention in microfilm, in computer, or

any other modePatient file (OP & IP)

OP cases not admitted53

of last visit of the patient YES NO

Casualty Record i. Medico legal cas es

ii. Ordinar y cas es 53

,,,, NO

NO

X-RAYS Outpatient x-rays Inpatient x-rays Casualty x-rays

551

,,,, ,,

NONONO

Registers: Birth register 2 of last entry in the register YES

Deaths register Adm. & Discharge register

Hosp. Master register Medico legal register Operation register IT

Ward Adm. & Discharge reg.

Narcotic register Infection register

X-ray register Laboratory register

2 2 2 2 1 1 1 1 1

1

,,,, ,,,,,,

,,,,,, ,,,,

YES

YES YES

YESNO

NONO NONONO

Index: Disease index

Permanently either in physical or computerized form

YES

Operation index Patient Master Index IT

Physician 1

,,,,

The physician left the hospital.YESYESNO

Report: Daily ward census- report

Daily statist report Monthly report

Yearly report Duplicate. Lab/x-ray

report

1115

1

of the report,,,,,,

,,

NONONO NO

NO



92

How long medical records should be preserved:

In the absence of national or state laws, the hospital or health institution can have their own retention and preservation policy that will be applicable in the court of law.

Consumer Protection Act 1986: Under the provisions of the Limitation Act 1963 and Section 24A of the Consumer Protection Act 1986, which dictates the time within which a complaint has to be filed, it is advisable to maintain records for 2 years for outpatient records and 3 years for inpatient and surgical cases. However the provisions of the Consumer Protection Act allows for condoning the delay in appropriate cases. This means that the records may be needed even after 3 years. It is important to note that in pediatric cases a medical negligence case can be filed by the child after acquiring the age of majority.

The Medical Council of India guidelines also insist on preserving the inpatient records in a standard prescribed form for 3 years from the commencement of treatment. The records that are the subject of medico-legal cases should be maintained until the final disposal of the case even though only a complaint or notice is received. It is necessary that the Government frames guidelines for the duration for which medical records are preserved by the hospitals so that hospitals are protected from unnecessary litigation in issues of medical records. The provisions of specific Acts like the Pre Conception Prenatal Diagnostic Test (PNDT) Act, 1994 (PNDT), Environmental Protection Act, etc. necessitate proper maintenance of records that have to be retained for periods as specified in the Act. Section 29 of the PNDT Act, 1994 requires that all the documents be maintained for a period of 2 years or until the disposal of the proceedings. The PNDT Rules, 1996 requires that when the records are maintained on a computer, a printed copy of the record should be preserved after authentication by the person responsible for such record.

Preservation Period for legal cases: Medico legal cases: where often the medical records are required to prove medical history / treatment given, medical negligence, etc. and especially in road traffic accidents

Insurance cases: where the insurance company

wants to review the medical records verify the claim

Workmen’s compensation cases: In cases where an injury occurs to a workman out of and in the course of employment.

Criminal cases: to prove the nature, timing and gravity of injuries.

Records Retention: Medical records are created when first time patient visits the physician or hospital. The medical record is used for various uses including patient continued care, medical education, research, public health, insurance, legal, administrative performance, and morbidity and mortality control aspects and information need to be sent to state, national or international levels etc. The medical record maintenance processes include various methods such as filing original records in filing shelves, use of microfilm or microfiche, scanning to optical disk, and off-site storage of records or in entire information in computer server.

Retained record must serve to:

• Ensure patient health information is available to meet the needs of continued patient care, legal requirements, research, education, and other legitimate uses of the organization

• Include guidelines that specify what information is kept, the time period for which it is kept, and the storage medium on which it will be maintained (e.g., paper, microfilm, optical disk, magnetic tape)

• Include clear destruction policies and procedures that include appropriate methods of destruction for each medium on which information is maintained

There is no single standardized record retention schedule that organizations and healthcare providers must follow. Instead, a viable variety of retention requirements must be worked out to create a amenable retention program. To begin creating a record retention schedule, organizations and healthcare providers should use central /state record retention requirements if any, found central record retention requirements.

State Record Retention Requirements:Each state may have individual specific retention record retention policy, if so, one has to observe those laws and retain records accordingly. In the absence of central or state laws for retention, the organization or institute can develop their own for



93

day to day practice taking care of minimum required period records to be retained to avoid any legal or administrative issues.

If the patient is a minor, the healthcare provider or institution should retain health information until the patient reaches the age of majority (as defined by state law) plus the period of the statute of limitations so that the child after reaching majority, may decide to file a case or not, for that some countries allow three more years after attaining majority to file the case or not. The country’s law fixes 18 years to be a major, the record for newborn to be retained for 21 years. A longer retention period is prudent in most of the legal potential cases. In some countries have retention of records requirements for various needs of agencies such as accreditation, some research organization in collaboration with government, organizations with special patient populations need to go one step further in developing a records retention schedule? Special populations such as minors, behavioral health, or research patients may be governed by other regulations. The Food and Drug Administration, for example, requires research records pertaining to cancer patients be maintained for 30 years.

Active and Inactive records:Once the retention schedule has been determined, the next step is to identify active and inactive records. “Active” means that the records are used on a routine basis for patient care, activities such as release of information requests, revenue integrity audits, or quality reviews.

“Inactive” means that the records are used rarely but must be retained for the purpose to meet the determined retention period. Inactive records usually involve a patient who has not sought treatment for a long period of time or one who completed his or her course of treatment.

Defining active and inactive records also may depend on other issues such as availability of physical file space, availability of off-site storage and the amount of research done, and administrative or legal needs of record. Even record is active, due to lack of filing space, the institutions may decide to keep for a year after last visit to outpatient department or date of discharge in active filing area and later shift to inactive filing space which is away from the main activity area.

Cutoff date for deciding record to be inactive:Each organization should determine a cutoff point (usually a last visit to outpatient facility or date of discharge) that indicates the time at which a record becomes inactive. In deciding the cutoff date, the following to be considered:

• How often are the records retrieved (e.g., daily, weekly, monthly)?

• What is the total retention requirement?

• What is the size of the record (a large long-stay record or a short emergency record)?

• What are the physical constraints (e.g., lack of file space, lack of off-site storage)?

• What activities or functions require routine access to the record (e.g., quality reviews, release of information)?

Identifying and maintaining active and inactive records is an important step in the successful maintenance of a filing system. Once the organization defines active and inactive records, the purge process can begin.

Destruction of Patient Health Information: Destruction of patient health information by an organization or healthcare provider must be carried out in accordance with central and state law pursuant to a proper written retention schedule and destruction policy approved by appropriate organizational parties. Records involved in any open investigation, audit, or litigation must not be destroyed until the litigation case has been closed.

As with record retention, there is no single standard destruction requirement. Some states require organizations create an abstract of the destroyed patient information, notify patients when destroying patient information, or specify the method of destruction used to render the information unreadable. Organizations should reassess the method of destruction annually based on current technology, accepted practices, and availability of timely and cost-effective destruction services.

In the absence of any state law to the contrary, organizations must ensure paper and electronic records are destroyed with a method that provides for no possibility of reconstruction of information. Examples of destruction methods are provided below:

Paper record methods of destruction include burning, shredding, pulping, and pulverize.



94

• Microfilm or microfiche methods of destruction include recycling and pulverizing.

• Laser discs used in write once-read many document-imaging applications are destroyed by pulverizing.

• Computerized data are destroyed by magnetic degaussing.

• DVDs are destroyed by shredding or cutting.

• Magnetic tapes are destroyed by demagnetizing.

Organizations must maintain a register or certificate of the destruction of health records permanently and include the following

• Date of destruction

• Method of destruction

• Description of all the disposed records including the numbers of the records

• Inclusive dates

• Persons names under whose supervision the documents were destroyed

• A statement that the records were destroyed in the normal course of business

• The signatures of the individuals supervising and witnessing the destruction

Conclusion:The Retention, Preservation and Destruction of Medical Records relating to Paper and Paperless matter is an extension of medical legal aspects of HIM profession, hence it would be prudent for HIM department to observe meticulously the procedures to avoid unnecessary legal complications.

Reference:Health Records Paper to Paperless by Dr. G. D. Mogli book published by JAYPEE BROTHERS Medical Publishers (P) Ltd. Year -2015 (pp 92-93)



95

Introduction:“The patient is the center of medical universe, around which all our works revolve and towards which all our efforts tend”, and this quotation by John B. Murphy holds good for years to come and every there is a trend how well the patient care can be improved and with all scientific improvements, it is really astonishing to see that the patient care has implored a lot when compared good olden days. Any hospital is measured in terms of patient care, efficiency and service. To achieve this is the responsibility of all who have anything whatsoever to do with the care of patient to make every effort to ensure that all patients received the best possible care with minimum delay with utmost skill and efficiency and with personal consideration and tenderness.

Categories of Personnel in Patient Care: Two important categories of personnel who involve directly patient care are doctors and nurses, who in turn require the collaboration assistance and service of many other professional and non-professional personnel of various departments such as laboratory, radiology, dietary, pharmacy, C.S. S. D., medical records, workshop and most importantly the administrative. Because of this extensive division of labor and accompanying specialization of work, practically every person working in the hospital depend upon some persons or other for bringing out effective patient care. Consequently, the hospital has developed a rather intricate and elaborate system of internal coordination. It is also interesting to note that unlike industrial and other large scale organizations, the hospital patient care relies very heavily on the skills, motivations and behaviors of its members for the attainment of adequate coordination.

Ward workflow is variable and irregular: The flow of work is too variable and irregular to permit coordination through mechanic standardization. And product of the organization patient care is itself individualized rather than uniform of invariant. Because the work is neither mechanized nor uniform

Organization of patient care in the ward

Dr. G. D. Mogli, Ph.D., MBA., FHRIM (UK), FAHIMA (USA)Visiting Professor, Medical Informatics, MGM Sciences, Maharashtra, India

Former World Health Organization [email protected] and www.drmogli.com

or standardized, because it cannot be planned in advance with the automatic precision of an assembly line, the organization must depend a good deal upon its various members to make the day to day adjustments which the situation may demand, but which cannot be possibly be completely detailed or prescribed by formal organization rules and regulations. This is all the more essential, moreover, one takes into account the fact that the patient who is the center for all activity in the hospital, is a transient rather than a stable element in the system. So the hospital is human rather than a machine system. The patient is not a chunk of raw material that passively goes through an ordered progression of machines and assembly line operators.

Nursing service provide safe care: Nursing service provides safe, effective and well planned nursing care, for patients and as a result of the development of nursing as a science, it has become a highly complex function that demand much training and skill. This department has constant contact with patients and naturally it requires the coordination of all other services for best patient care. Central and coordination will be possible only when there is proper organizational structure and adequate supervision. Activities to be performed and personnel needed must be grouped in such a way as to achieve smooth functioning. Lines of authority should be clearly, marked and above all everyone should know for what, to whom and for whom the nurse is responsible. The best way to achieve this is through construction of an organization chart. All of the activities involved in personnel administration of the hospital as a whole and particularly in ward are duplicated to a considerable extent in the department of nursing and therefore, it is advisable that each category of nursing personnel should have job description and manuals of procedures and standard should be developed and departmental policies consistent with those of entire of hospital should be determined. In good personnel administration the two most important factors are adequate in-service training and effective supervision.



96

Figure 1: Nursing staff attending to the inpatients occupying a general ward beds

Objective of good nursing service: Since one of the objectives of good nursing service is to provide nursing economically and safely to utilize each worker at her maximum degree of skill, it is important that provision be made for in service training for all categories of personnel. An in-service training for all employees should serve three purposes:

• Introduction of new worker to the hospital / department which she is assigned.

• On the job training for specific activities, she has to perform at any given time.

• Continuing development for improved services and for greater responsibility according to the worker’s interest and potentialities.

Supervision deals with those functions which are designated to help personnel perform the assigned tasks in such a way that the combined efforts of all achieve the purposes and standards of the organization. Obviously the functions of supervision are found at all levels of management. They do not change except in degree and in the proportion of time which is spent in performing them.

Factors for better patient care: The following factors are to be considered for better patient care and smooth functioning of nursing department.

• Adequacy of material facilities

• Financial consideration

• Size related to features of hospital

• Composition and distribution of therapeutic staff

• Absenteeism and turnover among nursing personnel

• Organizational coordination and intra organizational strains

• Hospital committee

• The performance of Para-medical departments.

Maintenance of records in the ward:Records and reports are an important means of controlling the nursing services. The ward sister is usually responsible for the following:

1. Records relating to the care and treatment of patient:

• Admission record,

• Discharge summary

• History and Physical Examination

• Labor record

• Consultation record

• Laboratory and x-ray Master sheet

• Anesthesia record

• Operation record

• Progress record

• Doctor’s order

• Nurse’s record

• In-take and output record

• T.P.R. chart

• Admission and Discharge order

2. Maintenance of stock books:

• Drugs

• Tablets

• Injections

• Linen

• Diet

• Stationeries

• Instruments

• Furniture

• Crockery’s and glass ware

3. Hospital Administrative Records:

• Census report (Admission and discharge register)

• Paying ward records

• Permission for surgical operation

• Notification of seriously ill patients

• Emergency operations

• Death and discharges

• Medico-legal cases

• Incidence cases

4. Ward Maintenance Register:

• Ward Maintenance

• Sanitary

• Pantry

• Equipments



97

5. Attendance registers of working staff in the ward

6. Nurses treatment registers (day and night report of the condition of patients)

1. Records relating to the care and treatment of patients: From the time a patient is admitted into the sward and till the case papers are handed over to census clerk after discharge of the patient the sister-in-charge of the ward will hold full responsibility for the safe custody of the case papers. She is also responsible for seeing to it that the privileged nature of the medical record is guarded. She must make certain that no one has access to the medical records during hospitalization of patient except persons concerned with the patient care. She must likewise see it that all medical records of patients are kept in a designated place in the ward, that they are not removed except when a patient is taken to another department for treatment, examination, or study, that no sheets are removed for any reason and that all laboratory, x-ray and other reports coming to the wards are at once attached to proper medical record. The sister should ensure for the completion of records day to day and especially the bed side nurse’s record should be recorded as and when the treatment is rendered.

Regarding bed side nurses record in most hospitals, the value is not felt and moreover, even, if they maintain it is not up to the standard and it is neither reveals any information about patient care neither it becomes part and parcel of patient’s record. As a matter of fact, it should give vivid picture of observation, treatment and services rendered by them to patient in the absence of the physician and thus serving as a means of communication between the doctor and the nurse, as the nurses change shifts and do not always see the doctor. The nurse’s record serves 4 major purposes.

As a record of the patient’s condition during the physician’s absence: It is a record of pertinent facts supplied by the nurses and gives the physician a clear perspective of this patient’s progress during his absence from the hospital. The entire plan of treatment may depend upon the information recorded. It is not an over statement to say that accurate results of treatment cannot be determined without correct and complete nurses’ notes. With the help of intelligently recorded bed side notes,

the physician should be able to watch his patient’s progress even though he visits the hospital but once a day.

As a time saver for the physician and an elimination of errors: If no written record of the patient’s hour-to-hour progress were available each person attending the patient would have to be told individually the details of the case. Thus, not only much time would be lost, but more unfortunately, such verbal instructions would tend to inaccuracies which might result in errors in medication or other treatment.

As a proof of work done: It is essential for the nursing staff to record work done as instructed by the physician so that he may note the results and determine the future course of treatment. If used as evidence in a legal cause, the nurse’s notes would serve as protection for her and the physician.

To complete the medical record: Nurse’s notes serve also to round out and complete the information in the medical record. After being filed following discharge of the patient, they may be used for group studies, for reference in the interest of patient in subsequent illness and for similar purposes. They are lacking in usefulness if they do not give a complete day-to-day report of progress. Similarly, other two important two records pertaining to nursing section are the T.P.R. and Intake and Output records which are essential for better patient care.



98

Introduction:Medical Record documentation is parallel to medicine. In the modern world Medical Records management plays a vital role in healthcare delivery system. The Medical Record is defined as a compilation of pertinent facts of a patient’s life and health history, include past and present illnesses and treatments, written by the health care professionals contributing to the patient care.

Patient Medical Record shall contain sufficient information to clearly identify the patient, compiled in a timely manner, support the diagnosis, justify the treatments and accurately and adequately document the course of care and end results.

Medical Record documentation also serves as a legal document to prove that a certain treatment is given to a patient and it is often called as “the witness that never dies.”

Medical Records is a valid source of reference when it comes to audit of coding, billing and reimbursements. Insurance companies verify the Medical Records of their clients to see whether the billings and services rendered is parallel. Having a good and organized Medical Records along with team work of the whole institution will not only benefit the patient but also the status of the medical institute as well.

Medical Records Audit:Medical records audit plays an important role in identifying the areas that needs improvement in patient care and corrective measures in existing documentation practice both in the outpatient and inpatient documentation systems. This corrective measure is often referred to as the Clinical Documentation Improvement program. The main objective of the Clinical Document Improvement program is to create medical records that fulfill the important features of Accuracy, Consistency, Completeness and Security.

The auditor would patiently look for defects in the Medical Record documentation process employed by the health care provider. The main objective of

Medical Records Audit Helps in Improvement of Patient Care

S. DEIVASEELI, MA, BMRSc, MBA (HM)MEDICAL RECORDS MANAGER

G. KUPPUSWAMY NAIDU MEMORIAL HOSPITALCOIMBATORE, TAMIL NADU, INDIA

[email protected]

conducting a Medical Record audit is to improve the various areas associated with documentation and it should never be a fault finding exercise. As the Medical Record contains sensitive information regarding the providers and patients, the Medical Record data is usually governed by a set of strict rules and regulations set by authorized bodies like Medical Council, Ministry of Health and World Health Organization. Based on these rules and regulations every hospital should develop their own policies and procedures to be adhered in their organization.

Medical Record Standards:The Medical Record must be complete and accurate.

It is important that it contains patient identification data such as name, age, sex, date of birth, ID number, parent or guardian name, contact numbers, email id etc., During the first visit of the patient all these information is to be recorded and updated as and when required on written request along with valid proof.

Legibility of the record should apply at all times. Details about the past history of the patient and other relevant information such as the past surgical procedures undergone, allergies and other treatments involved must be clearly documented in the record.

All information listed in the medical record of each patient must be dated and signed by the authorized personnel. The chief complaint of the patient must be clearly indicated on the Medical Record.

Every day the attending physician is to record all observations, diagnosis and findings in the medical record.

Studies conducted including X-rays, laboratory tests, drugs prescribed and therapies must be written in the patient’s record.

Important details about all the practitioners giving the service must be included in the record. It includes the name and the designation of the attending physician.



99

The record must contain all other significant information about the patient. Some of which are immunization history, background history on smoking or substance abuse e.g. alcohol, emergency service record, and any other previous hospital confinements.

A good medical record must be parallel with the current condition of the patient. It must reflect the true condition of the patient.

The primary language spoken by the patient must be included in the record. This is to help the patient provide the right information they need for directions of medications and other important issues. If translation is necessary, it is the job of the service provider to give the client such service as and when required.

Important Attributes Verified during a Medical Record Audit:The quality of medical records maintained by a health care institution has the ability to impact the patients and physicians involved in the health care delivery system. In order to ensure that the medical records maintained satisfy the guidelines set by the international and national bodies, the audit primarily looks in to the following four characteristics of a medical record document.

1. Data ConsistencyThe collected data should not contradict with each other and also the standard operating guidelines set by the institution. If the data collected is highly inconsistent, the medical care provider would not be able to arrive at correct decisions or recommendations which will directly affect the treatment. Hence it is absolutely vital for the medical records to have consistent data.

2. CompletenessIf the medical records are not complete, it is practically impossible for the care giver to proceed to the next step. The physicians, the coders and the Medical Record Management professionals have to ensure that complete patient information is acquired either directly from the patients or through legitimate sources as specified in the Medical Record policies.

3. Accuracy of Medical Records dataIn order to ensure that the data collected is accurate in nature proper training programs have to be conducted at regular intervals for the Physicians,

Nurses and Paramedical professionals involved in the patient care. This can be verified during the periodic Medical Record audits.

4. AccessibilityMedical Record audits prove whether the Medical Record data access is provided as per the roles and responsibilities assigned by the care giver. The medical record data should be accessible only based on the role played by the employee and the data should be stored in a secured mode always.

Medical Records Audit Guidelines

Each hospital should complete at least 1 audit per year.

A random sample of 5 to 10% of discharges in a given month or 10 records of a department (whichever is higher) should be audited.

Records are selected using a printout of the Medical Record or Bed numbers of all discharges in a month ordered by discharge date. Every 10th medical record number on the list is selected for audit. If the record selected is not available (for example the patient has been readmitted), the next record on the list should be selected.

The audit relates to documentation within the selected admission only.

Hospitals should designate an overall contact person or lead auditor for each audit.

Auditing should be completed within one week following selection of the records.

At the completion of the audit, the contact person or lead auditor should return the medical records to their original location.

Rating for satisfactory is 1, for unsatisfactory is 0 and not applicable is N/A.

Definition of satisfactory - a criterion is satisfactory only if all entries in that admission comply, example if 9 out of 10 medical entries are dated and 1 is not, then the result for that criterion is unsatisfactory.

Not applicable criteria - when summarising the results of the audit, criteria rated ‘N/A’ should be excluded when calculating the percentage of records that are satisfactory or unsatisfactory.

The audit results should be documented and a copy of the report sent to the Medical Records Committee for taking corrective and preventive action.



100

If the results of the audit indicate a problem area, this should be brought to the attention of the respecting health care workers, concerned departments, the hospital Medical Superintendent and the Director of Nursing. This is to improve the Clinical Documentation requirements as per the policies of the institution.

Subsequent audits should specifically consider whether the problem previously identified has been addressed.

Gknm Hospital - Medical Records Audit And Documentation Improvement Programme

Nurse’s Audit:Hospital Infection control Audit, Needle stick injury Rate, Catheter Associated UTI, Ventilator Associated Pneumonias Rate, Surgical site infection Rate, Central line BSI Infection, Hospital Nosocomial infection Rate, and Pressure ulcer Audit (Braden Scale), Peripheral Intravascular Line Related Phlebitis Surveillance.

Doctor’s Audit:Medicine Prescription Audit, Endocarditis Audit, Infective Endocarditic Audit, Maternal Death Audit, Perinatal Audit, Re-Exploration Audit, Sepsis Audit, Thrombolysis audit, LSCS Audit, Myocardial Infarction Audit and Medical Audit.

Quality Indicator’s Audit:Time of Initial assessment of indoor and Emergency patient’s, Initial Nursing Assessment, Adverse Drug Reaction, Drug chart errors, Re-Admission in 48hrs audit, Percentage of unplanned return to OT, Blood Usage Audit, Counter signed by the Consultants within 24 Hours, Nutritional Assessment Audit, Care plan Audit. Inpatient Records Audit or Deficiency Checking by MRD:Inpatient Records received within 48 hours from the ward after discharge of a patient – ward wise, department wise.

Expired patient records received within 72 hours from the ward after death of a patient – ward wise, department wise.

Number of records received without or incomplete Discharge Summary / Death Summary within the stipulated time.

Number of records received with incomplete admission record / face sheet

(final diagnosis, procedure, discharge / death date, cause of death, discharge status, medical officer and consultant signature).

Number of records received without consultant / medical officer signature, provisional diagnosis, plan of care, pain score, nutritional assessment in History and physical examination record.

Number of records received without physician progress notes, name and signature of medical officer in progress notes.

Number of records received with incomplete drug chart (name date time and signature, legibility of medicines name in capital letter)

Number of records received with incomplete / improper consent forms (correct procedure consent, diagnosis and procedure, risk factors, date of procedure, name and signature of patient / patient attender, witness and doctors signature).

Number of records received without operation record or procedure notes, date and time of procedure.

Number of records received without pre and post operative care evaluation of anesthetist

Number of records received with incomplete nursing documentation in the Initial Nursing Assessment forms, Medication Chart, Daily Nurses obeservation Record and Vital signs chart and ICU chart

Number of records received without Diet charts, Physiotherapy notes

After receiving the records in MRD, incoming records are entered in the HMS to track the records. All the records are assembled in chronological order, deficiencies are checked and completed, finally coded as per ICD10 before filing in the racks.

Identified deficiencies are grouped Department wise, Doctor wise, Ward wise and intimated to the concerned department, doctors and wards for completion through intranet mail to come and correct it in MRD within 7 working days.

All these data’s are collected, analysed and presented in Medical Record committee meeting in numerical and graphical presentation to take necessary corrective and preventive action.

We also conduct periodical training programmes for Doctors, Nurses and Paramedical Personnel involved in the patient care for the continuous improvement of clinical documentation, which ultimately benefits the patients in improving the quality care.



101

Medical Record Audit by MRD Oct 2015

S.no Particulars No of Discharges% of

Compliance% of Non

Compliance

1 Emergency Record, Patient Status at the time of shifting from ER to ICU – Doctor’s Signature 2769 99.82 0.18

2 History and Physical Examination record – Consultant signature within 24 hours of admission 2769 99.78 0.22

3 Physician Progress Notes – Date and signature 2769 99.60 0.44 Cross consultation record deficiencies 2769 98.81 1.19

5 Discharge Summary – Doctor’s Signature 2769 99.39 0.616 Drug Chart – Doctor’s Signature and time 2769 99.64 0.36

7Front Sheet (Provisional Diagnosis, Final Diagnosis, Procedure, Cause of Death, Discharge status, Medical Officer and Consultant Signature)

2769 99.21 0.79

Discharge summary Errors - Non Medical

CRITERIAS Total Discharges Non compliance %Name, Age and Gender 2769 17 0.61Correct Diagnosis 2769 1 0.04Procedure Name and Date 2769 17 0.61Correct Discharge / Death Date 2769 10 0.36Investigation Summary Missing 2769 4 0.14Discharge Status and Advice 2769 4 0.14

Inpatient Record Documentation Audit CRITERIAS Total Non Compliance %

Compliance on Initial Assessment by Medical Officer 2769 2 0.07

Compliance on Care plan by Consultant 2769 2 0.07

Documentation of Pain score by Medical Officer 2769 4 0.14

Counter signed by the Consultants within 24 Hrs 2769 4 0.14

Compliance on Nutrional Assessment by the Dietitian 2769 1 0.04

Compliance on Initial Nursing Assessment by S/N 2769 3 0.11

Conclusion:As we all know we are living in the era of litigations and Medical Records is the only document which speaks about the type of care given to the patient in the court of law. A Good Medical Record reflects Good Medical care and Poor Medical Records always reflects Poor Medical care.

It is said a Doctor who cannot take a good history and a patient who does not reveal the complete history are in danger of giving and receiving bad treatment – Author Unknown

With the number of patients dying every year from preventable medical errors, it is imperative that we embrace available technologies and drastically

improve the way medical records are handled and processed – John Porter.

I take this opportunity to thank the Organising Committee members of MEDRECON - 2015 for conducting this conference successfully and also given me a chance to present my paper in this august gathering which will go a long way in the improvement of patient care through Clinical Documentation Improvement program.

References:• Medical Records Management –Edna K. Huffman• Medical Records Manual for developing countries

published by WHO • Guidance of clinical documentation improvement

toolkit –AHIMA• Clinical audit - CDI forum



102

The people of our society are becoming more and more health conscious and aware of things happening around them. Patient safety and security has been gaining importance day by day. They also know their rights and do not mind to approach consumer forums if required.

Every doctor wants to improve his/her professional efficiency. There is a need for him/her to provide quality patient care services. There is need to identify the shortcomings if any during the process of patient care to avoid such shortcomings in future. Medical audit is a tool which helps to indentify the gaps of quality healthcare and rectify them.

Medical audit involves analysis of clinical care as well as paramedical services.

Clinical care assessment involves direct patient treatment aspect. Similarly surgical audit, nursing audit, specific clinical department audit and diagnostic department performance evaluation can be done.

HistoryOne of theoldest clinical audits was done by Florence Nightingale (1853 – 1855), she observed the infection rates of war wounded reduced from 40% to 2% by improving the cleanliness, Hygiene and general sanitation andthereby reduce the mortality rate.

Over the years, the subject of Medical Audit / Clinical Audits as evaluation process being used for improving performance.

Types of audit1. Standard based audit

2. Review & evaluation of serious adverse events.

3. Peer review of quality care.

4. Patient surveys and focus group – satisfaction study.

What is audit?Audit is a process of reviewing of delivery of care (Evaluation of data, documents and resources)to check performance of system meeting specified standards and indentify the gaps, so that they may be corrected. Audit aims at fact finding and not fault finding.

Medical Audit

Who will carry out medical audit? By a multi speciality committee headed by MS/Hospital Administrator/COOwith Representatives from clinical departments, nursing representatives and Para medical staff as required.

Top management’s initiativecommitment is absolutely necessary.

Patient’s participation through feedback.

Stages of medical auditAudit programmes need to be planned and carried out periodically.

1. Planning for audit

2. Standard/ criteria selection

3. Measuring performance

4. Making improvements

5. Sustaining improvements.

Persuading hospitals and clinicians to undertake and apply clinical audit, periodical evaluation for further improvement are the key to success.

Confidentiality and ethical issues are to be given due respect during the audit process.

A very good medical record keeping, data collection and analysis of data will help in carryout the audit process easily which is mainly contributed by the medical record department.

References:• Clinical Audit :https://en.wikipedia.org/wiki/

Clinical_audit

• A practical Guide To Clinical Audit :https://www.google.co.in/search?q=A+Practical+Guide+To+Clinical+Audit&rls=com.microsoft: en-US:%7Breferrer:source?%7D&ie=UTF-8&oe=UTF-8&sourceid=ie7&rlz=1I7NDKB_enIN563&gfe_rd=cr&ei=5yxdVsr0LPOK8QeW7qto&gws_rd=ssl

• National Accreditation Board for hospitals and health care providers,3rd Edition, November 2011

• Medical Audit:slideplayer.com/slide/7403810/Dr Preeti Thaware

• Dr. (Lt.Col) N.K.Sarangi



103



104


Veiled Rebecca, Salarjung Museum

NTR Garden

Golconda

BirlaMandhir

Cyber Tower

Shilpa Ramam

Venue


SOUVENIR

with Theme BETTER HEALTH INFORMATION MANAGEMENT

FOR BETTER HEALTH CARE

HIM INDIA INFO - 20154th - 5th December 2015

Sponsors :

Health Informati on ManagementAssociati on (HIMA) INDIAconducted 1st Nati onal Conference and Exhibits on HIM and IT under the guidance of Organizing Chairman, Dr. G. D. Mogli, PhD, MBA, FHRIM (UK), FAHIMA (USA)

In collaborati on with
