Beginning the Journey

1
Beginning the Journey
Automating Clinical Documentation

• Sally Carr BSN RN,C

2
The Decision

• No sensible decision can be made any longer
  without taking into account not only the world as
  it is, but the world as it will be.
  Isaac Asimov

3
Forces of the Future

• Institute of Medicine
• Healthcare practitioners should adopt the
  Computer-based Patient Record as the standard for
  medical and all other records related to patient
  care
• JCAHO
• Integrated Health Care Delivery

4
The Challenge

• Defining technically acceptable systems that
  support the delivery of cost efficient, quality
  care, and that are able to communicate health
  care data enterprise wide, across the continuum
  of care.

5
The Foundation

• What is Your Institutions Strategic Plan?
• What is Your Integrated Delivery System?
• What is the Goal of the System?
• Who is on the Selection Team?

6
Words to the Wise

• Plan, Top Down.
• Design Implement, Bottom Up.

7
Institute of Medicine Definition

• A CPR is an electronic patient record
  that resides in a system designed to support
  users through availability of complete and
  accurate data, practitioner reminders and alerts,
  clinical decision support systems, links to
  bodies of medical knowledge and other aids.

8
IOM Gold Standard (abbr.)

• Provides Problem Lists
• Measures Health Status Functional Levels
• Documents Clinical Reasoning/ Rationale
• Provides Longitudinal and Timely CPR Links with
  Other Patient Records
• Guarantees Confidentiality and Audit Trails

9
IOM Standards Vendors

• 1998 CPR Systems Review
• ADVANCE for Health Information Executives(www.adv
  anceweb.com)May 1998
• Compiled by William F. Andrew, PE

10
Request for Proposal

• IOM Gold Standard
• Interdisciplinary Documentation
• Individualizing Plan of Care
• Clinical Paths
• Decision Support
• Training

11
Mechanics Methods

• Site Visits
• Site selection
• Observations Response time Sticky notes
• Questions Vendor training User satisfaction
• Lets Make a Deal
• Big bang or phased
• Speed vs. Quality Control

12
Attitude is Everything

• Most of us are about as eager to be changed
  as we were to be born, and go through our changes
  in a similar state of shock.
• James Balwin

13
Implementation Issues

• 24 X 7 Coverage
• Who, how for how Long
• Tracking Problems and Changes
• Vendor issues
• Communication to users

14
Avoidable Pitfalls

• Inadequate User Support
• Inadequate Training
• Inadequate QA
• Modular vs. Integrated
• Poor Physician Involvement
• User Expectations

15
Downtime Disaster Recover

• One of the extraordinary things about human
  events is that the unthinkable becomes
  thinkable.
• Salman Rushdie

16
Field Help

• Helpdesk One Stop Shopping
• Poster Boards Visual Aids to Learning A New
  Language
• Go-Live Support Options

17
Life Beyond Go-Live

• Managing Requests For Change
• Maintenance vs. new implementation projects
• Prioritizing requests
• Expectations and Exhaustion
• Some things were never done
• What was done, will need to be redone
• What was asked for is not what is wanted

18
The End?????

• The road to hell is paved with
  works-in-progress.
• Philip Roth