Local Washington hospital implements DocuWare to link information entered into their Health Information System, Meditech, with other crucial healthcare documents such as physician order summaries, lab results and registration documents. With one search, hospital staff has access to information at the point of care, delivering a higher quality of service to their patients. In addition, manual chart management time has been reduced now that transferring records to external coding companies has been automated.
Initial Situation
Mason General Hospital & Family of Clinics (MGH&FC) serve the 45,000 people who live in Mason County, Washington year round, as well as the 200,000 seasonal residents. It is a 25 bed public hospital that is rated as a level 4 trauma center. Most level 4 trauma centers offer only ER triage and transfer to a larger facility, however MGH&FC offers a wider range of services including surgery, intensive care, pediatric care, obstetrics, diagnostic imaging, as well as respiratory care and chronic care for diabetes patients. The hospital’s nine attached clinics further expand services to include: orthopedics, podiatry, women’s health, pediatrics, family practice, internal medicine and optometry.
MGH&FC first used microfiche and later document imaging to store its records. When it came time to update their system, it was determined they wanted to do more than store old records so they focused on finding a solution to not only import documents and data from their current system, but was powerful enough to streamline their medical records processes throughout the hospital and address short-falls of the current system.
Requirements
They wanted a system that could work hand in hand with Meditech, their Health Information System, to provide the staff with real-time patient information throughout all areas of the hospital and clinics. Another need was to streamline their information processes with automatic indexing and easy retrieval to reduce the amount of staff dedicated to scanning, indexing, and managing paper medical charts. Additionally, the new system needed to simplify the process of transferring electronic information to external medical coding companies and be in solid compliance with HIPAA regulations.
Solution
An Authorized DocuWare Partner (ADP) met with MGH&FC to evaluate their existing system and stated goals. The ADP recommended a DocuWare Integrated Document Management system that includes StapleWare workflow automation modules as an integral part of the solution.
Tasks
- Implement a solution that can integrate with Meditech
- Automate medical record processing and reduce the use of paper charts
- Simplify the transfer of electronic information to external medical coding companies
Benefits
- Instant access to completed medical records provides a higher quality of care
- Quicker access to shared information between staff and labs
- Increased transparency in patient care status
- Faster coding means improved accounts receivable
Organizational Benefits
When a physician or nurse is treating a patient they use the Patient Care Inquiry (PCI) module of Meditech to view the information that has been typed into the patient’s care history, lab or registration module. However, a patient’s medical record is also made up of many other documents not found in Meditech such as advance directives, legal documents, test results from a third party facility, and even a copy of a patient’s insurance card and picture ID.
With DocuWare installed healthcare providers now have access to a patient’s medical record at the point of care. When a physician searches for a patient in the PCI module of Meditech, the DocuWare Integration to Meditech PCI module works in the background to automatically open a DocuWare results list. The results list is filtered by document type to provide healthcare professionals with the additional information they need such as an advance directive, patient ID or external lab reports, but would hide documents not used to determine treatment such as a consent or registration form. This system makes finding information quick and easy. Physicians only have to login to Meditech and perform one search to get all the information they need, immediately, right at their fingertips.
“Putting the complete medical record into the hands of our physicians and nurses, easily, at the point of care is a vital part of delivering a higher quality of care to our patients,” said Laura Grubb, Director of Health Information and Privacy Officer for Mason General Hospital & Family of Clinics.
The hospital worked with their ADP to link Meditech and DocuWare. Meditech is the source of patient index information for the documents stored in DocuWare. As patient information is entered or changed in Meditech it is synchronized with DocuWare using HL7 integration, a healthcare specific data exchange format, to pass information to DocuWare by writing it to a table and having DocuWare run an automatic synchronization process. With this happening in the background, the medical records are always indexed correctly and searching for information is simplified.
ER Records Benefits
Another area to benefit from their new system is transferring medical records from the Emergency Room to a third party medical coding company. Patients treated and released from the ER have a medical record between 8-20 pages long. Prior to implementing DocuWare these electronic records were printed, bound and sent via courier to the medical coding company. Late documents that should have been part of the record were sent by fax and the coders would get these loose sheets of information and have to determine which record they belonged to, slowing the process for both parties. Because a sizable portion of the hospital’s revenue comes from ER visits, streamlining this process was crucial.
Today, this process is automated. Once a record is complete containing the face sheet, consent form, dictated report and electronic physician signature, it is marked for export and twice a day, automatically sent via StapleWare Process Server to the medical coding company. After each upload both the hospital and the coding company receive an e-mail notification that the documents were exported successfully along with the log file from the transaction. If the documents were unable to export, an error message is sent defining the error and alerting both companies. A business critical process that took upwards of 5 hours a day has been completely automated, eliminating manual processing and speeding data delivery and the return of coded documents.
MGH&FC plans to further expand DocuWare’s role in the management of their ER medical records. Like many other hospitals, the ER department does not use the same medical record software as the rest of the hospital. Instead they are using T-Systems, an ER records solution specifically designed for the needs of Emergency Room physicians and treatments. Having two medical records systems allows physicians to use software customized for their needs, but makes sharing information between the two programs difficult. Instead of ER records being printed and then rescanned, the records will be transferred into DocuWare though the TIFFMAKER print driver which electronically prints the record and automatically indexes the information. This makes information and treatments performed in the ER department almost instantly available through MGH&FC’s linked Meditech and DocuWare solution.
Diagnostic Imaging Department Benefits
The Diagnostic Imaging (DI) department also went paperless. When patients arrive at the Diagnostics Imaging department they have already been registered as a patient at the hospital. They usually have with them a script for a test. The DI department scans the script and indexes it, “marrying” it to the registered patient. The script is routed through their process using electronic stamps. By converting the scripts to electronic documents and entire process became paperless.
By moving to DocuWare, MGH&FC was able to control which employees have access to information for a certain period of time. For example, the DI department has access to patient information during the scheduling and administration of a test. Once the test is complete the information is made available to medical billers. The DI department will then have access to the information for only 30 days.
Lab Department Benefits
The hospital Lab implemented electronic workflow and has seen its processes simplify dramatically. Documents received by the lab can have several orders with a various number of tests from a single lab draw such as 3 times in one week or every week for the next year. Regardless of how many test are done the Lab needs to retain the order document. The Lab uses DocuWare to directly monitor what draws are in process. Every lab draw is indexed as either, WAITING, HAS DRAWN, or WAITING FOR RESULT. At a glance the Lab manger will know what is going on and how many patients are waiting for a draw. DocuWare can be even be used to determine where in the hospital the patient is, i.e. ER, inpatient or outpatient. Electronic stamps route the order document and specimen collection form to testing and billing, giving transparency to the process and speeding healthcare.
Once a patient is discharged from the hospital, discharge instructions are printed for the patient and simultaneously stored via automatic indexing in DocuWare, eliminating the need to print and rescan the document into the medical record. This process has greatly reduced the amount of charts that need to be manually indexed by the Medical Records staff.
Conclusion
MGH&FC l is using DocuWare to unite information from many different departments and sources into one up to date electronic medical record. One search in Meditech brings up all relevant patient information, regardless of which software program the information was entered in. Patient information can be limited based on predefined criteria so that only the necessary information is available to hospital employees.
“Healthcare is complex, handling patient records shouldn’t be. DocuWare helps us manage our records so that we can focus on providing the best healthcare services possible to our patients. Putting the complete medical record into the hands of our physicians and nurses, easily, at the point of care is a vital part of providing a higher quality of care to our patients” said Grubb.
