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October 2006

E lectronic H ealth R ecord into the future D igital M edical R ecord Project aka Scanned Medical Record aka Clinical Patient Folder. October 2006. Introduction. Medical Record Information Storage & Retrieval Aid in diagnosis and treatment Communication & Teaching Investigation.

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October 2006

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  1. ElectronicHealthRecordinto the futureDigital Medical Record Project aka Scanned Medical Recordaka Clinical Patient Folder October 2006

  2. Introduction • Medical Record • Information Storage & Retrieval • Aid in diagnosis and treatment • Communication & Teaching • Investigation

  3. Background • Where is the RHH on this line? ??????????????????????????? Full paper Full electronic We’re probably about here right now – with very few medical record components created electronically We need an incremental transition step. There is a general expectation that we’ll be here in the future (2010? 2015?)

  4. Background • The RHH now has four wards located off-site. • Record availability is a Safety and Quality issue. • On average each year, 40 ‘record unavailability’ incidents are reported, relating to record tracking etc. • 5.5km of storage on-site; consumption growing at around 100-300 metres per year. • It was predicted that within 2 years, all available space for records on-site would be consumed.

  5. Project

  6. Project • Clinician-directed • InfoMedix’s “Clinical Patient Folder” product • Australian vendor who has worked hard with us to fully implement a system in less than 10 months! • Barcoded forms

  7. Project • Acquired hardware. • 4 scanning workstations • 1 server for Hobart, 1 backup server in Launceston, each with ≈ 5 years of storage. • Upgrade network including wireless • Additional personal computers

  8. How it works

  9. 2. New, empty current record folder created, with only alerts sheet and patient labels. 3. As care is provided, all documentation goes into the current record. 4. Upon discharge, the completed record is sent to PIMS, Medical Records. 1. Patient arrives at RHH Using the “current record” 6. The record is available electronically 7. Once all QA processes have been performed, the paper is shredded 5. The contents of the folder are scanned

  10. Sample • There is demand for a “one stop shop” for access to information held electronically • The InfoMedix software we are using will take information feeds from multiple sources • Electronic forms capability • One website, one username and password. • Pathology integrated at go-live. Working on implementing electronic signing of pathology results.

  11. Quality Control • Security & Backup. • More secure than paper – automatic audit trail generated, identifying all access to the record. • Apply ‘privileges’ to pages (eg. Where legislation mandates) • Previously, thermal-printed images like this would last ~ 5 years. Archives Act specifies at least 5 years (can be over 50). With DMR, image is now permanent. • Better backup – three different copies kept • Hobart • Launceston • Off-site tape backup • Previously no backup

  12. Conclusion • The Medical Record must transition from a paper based medium • DMR provides a cornerstone for future development • The platform installed at the Royal Hobart Hospital provides the basis for a fully integrated, complete statewide medical record. And arguably, an idea for other sites to consider.

  13. Conclusion

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