cpsi- electronic documentation

8/4/2019 CPSI- Electronic Documentation

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Electronic Documentation:

A New Direction for

Healthcare Information

Presented by:

Alexandra Zuniga, R.P.T.

Director of Rehabilitation

Pan American Hospital

January 24, 2007

Florida International University

Physical Therapy Program


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Five Main Goals of Healthcare

Information Systems:

Reduce medical errors and improve patient

safety.

Reduce duplication and waste.

Promote patient-centered care.

Give providers tools for better decision

making. Eliminate handwritten clinical data by 2015.


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Methodology for Choosing a Vendor

Pan American Hospitals leadership team

analyzed fiscal, clinical, and functional needs.

Seven vendors held presentations in a general

forum and individual departmental

presentations.

CPSI was chosen based on enterprise wide

software applications, ease of use,

functionality and cost.


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About CPSI:

Corporate Development

Computer Programs & Systems Inc. (CPSI) has been

serving the healthcare information needs of the

medical community for over 25 years.

Founded in 1979 and is headquartered in Mobile,Alabama.

Provides a complete patient care information system

from business office to bedside.

In 2005, CPSI was rated #31 on Forbes 200 Best

Small Companies.


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About CPSI:

System Product Development

CPSIs primary goal is to develop and support

quality application software for a totally

integrated system.

Over 540 medical facilities nationwide are

running the major application modules.

Over 200 Critical Access hospital client

facilities have undergone similar conversions.


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About CPSI:

Organizational Structure

Six major divisions

Information Technology Services

Financial Software Services Clinical Software Services

Programming Services

Administration Sales and Marketing


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Clinical and Patient Care

Applications

Electronic Medical Record (EMR)

Point of Care (POC)

Hospital Based Functions Computerized Physician Order Entry (CPOE)

Picture Archiving and Communication System

(PACS) Web Based Physician Access


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Portability of Systems

Mobile Cart Station

Wireless Laptop Tablets

The wave of the future.Wireless Personal Data Assistant (PDA)

Fingerprint Biometrics when signing on


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Main Application Software

Clinical Modules

(Physical Therapy System)

Enterprise Modules

(Enterprise Wide Scheduling)

Financial Management Modules

(Accounts Payable)

Miscellaneous Modules

(Archival Data Repository)


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Software Continued

Office Automation Modules (ClientWare Networking)

Patient Care Modules (Order Entry Systems) (Care Plans)

(Point of Care Systems)

(Electronic Forms Module)

Patient Management Modules (Electronic Claims Submission)

(Digital Signature Capture)


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Patient ManagementModules


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User Sign In


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Registration/ADT

Provides timely, accurate information on the

most critical aspects of hospital operations.

Manages patient admission, status, room

changes, charges, and discharge.

From pre-admission to discharge, keeps patient

information available to hospital staff.

Demographic data is stored and can be

transferred in the case of a re-admission.


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Sample Face Sheet


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Automated Registration

Documentation System (ARDS)

Helps streamline registration tasks.

Allows printing inpatient and outpatient forms

without having to change printers or paper.

Examples are face sheets and signature forms.

Eliminates card embosser.

Bar coded patient labels can be printed on asingle sheet of paper and be placed on patient

wristbands and documents.


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Digital Signature Capture

Compact devices store secure and legally bindingsignature to any patient document.

Reduces paper documents.

Forms include Admission Forms, TreatmentAuthorizations, Release of Information, etc.

Documents can include text, single or multiplesignatures, hospital specific information and can

automatically include demographic information. Integrity of signature is protected by requiring a new

signature if the text is changed.


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Health Information Services

Includes daily patient Census.

Includes patient accounting modules for

Diagnostic Related Groups (DRGs).

This supports the quality assurance/quality

control needs of insurance billing.

Also provides additional statisticalinformation.


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Indexes and Functions Available


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DRG Grouper and Reporting

Assigns DRGs from the diagnosis and

procedure codes.

Provides both concurrent and historical reports

on the factors that affect reimbursement by

DRG.

Provides hospital Administration and

Department Directors with the information

necessary for effective hospital management.


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Master Patient Index

It allows patient information to be unitized

and arranged in serial numbering systems.

It provides immediate access to patient

financial and medical data associated with a

patient stay.


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Sample Patient Index


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Chart Location/History Tracking

Allows the user to update and review the

patients medical record.

You can search for a patient chart on-line

using the account number by performing a

numeric look up or by patient name through

alpha look up.


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Point of Care Menu


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To search for a patients chart


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Using patient name


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Using patient account number..


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Sample Patient Chart


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Document Scanning

Documents like patients drivers license,

insurance cards, patient transfer orders etc. can

be scanned and stored electronically.

Scanned documents are available immediately

to authorized users and can be printed.

If used with the Archival Data Repository, this

can permanently include any document in the

patients historical records.


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Electronic Claims Submissions

Provides computer to computer link with the

Medicare intermediary to submit claims.

This allows the hospital to have increased

efficiency with its financial management.


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Quality Improvement

CPSI provides modules that can assist the user

in completing functions necessary for Quality

Assurance, Risk Management, Utilization

Review, Physician Credentialing and InfectionControl.

The hospital can change the system parameters

to meet its needs.


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Managed Care

This system can track various insurance plans

and the patients that are enrolled in them.

This information is stored during the

registration process.

Payment terms can be set up.

An unlimited number of healthcare networks

may be created.


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Patient Care Module


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Order Entry System

Effective alternative to written tickets.

Eliminates mistakes due to illegibility.

Establishes controls for accountability. The Rehab Department at Pan American

Hospital designed Order Entry categories by

discipline with drop down menus.


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Order Entry Menu


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All Ancillary Departments


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All Rehab Orders


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Specific Order Selection


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Sample Physical Therapy Order


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ChartLink Computerized

Physician Order Entry (CPOE)

Benefits include decreasing medical errors

which accounts between 44,000 and 98,000

deaths per year.

Customized by Pan American Hospitals

Medical Staff to fit their needs.

Physicians underwent training with ChartLink

Fair compliance due to resistance to change.


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CPOE Continued.

Medication Order Entry

Allows physicians to order medications and set

administration frequency and duration parameters.

The application is fully integrated with the patients

current clinical and demographic information.

Alerts can be set up to prevent adverse druginteractions and/or duplicate therapies.


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CPOE Continued.

Ancillary Order Entry

Allows physicians to order ancillary tests andtherapies.

Includes Rehabilitation orders for Physical andOccupational Therapy, Speech LanguagePathology and Orthopedic Technician services.

Can add additional pertinent information incomment section such as weight bearingstatus.


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Electronic Forms Module

Electronic forms replaced paper forms.

Forms are customized to needs and standards.

The Rehab department created forms using

existing forms and Medicare guidelines toassist in familiarity during the conversion.

The on-screen forms look like the forms they

replaced. Includes an anatomical diagram image feature

useful when documenting wound care.


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Flowcharts.


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Sample P.T. Evaluation


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Narrative Information.


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Sample of Anatomical Diagram


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Clinical Module

B fi f h Ph i l Th


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Benefits of the Physical Therapy

Module

Timely and accurate clinical information.

Maintains a journal of daily orders through theOrder Entry system which helps us

communicate with Nursing and Medical Staff. Allows department to receive orders from any

designated location.

Maintains technical, statistical and patientaccount information.

Improves overall efficiency.


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Medication VerificationSystem


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Medication Verification

The medication order can be placed by aPhysician through ChartLink (CPOE) orthrough Pharmacy using Order Entry.

The medication is pre-screened by amonitoring Pharmacy module for possibleallergies and/or drug interactions.

Final check is done at time of administrationby scanning patients label using barcodeverification.

S l All /D li t


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Sample Allergy/Duplicate

Medication Checks


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Medication Verification Continued...

Two bar codesone on patient wristband and

one on medication that identifies individual

medication and dosage.

The system compares the information from

both scans to the medication profile of

outstanding orders to assure a match-up.

If there is no match up, the system sends alertto prevent a potential medical error.


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Office Automation Module


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ClientWare Networking

Able to view on-line documentation to perform

chart reviews for current and discharged

patients.

Able to answer any Physician or Discharge

Planning questions from desk.

Able to view live Order Entry lists to check

if orders have been sent for a specific patientand discipline.


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Extra Features

Financial Information and account information

Insurance claims processing

Enterprise wide scheduling


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Summary

Hospital wide system that communicates across all

departments.

Covers clinical, demographic and financial

information. Electronic documentation decreases medical errors.

Stores information from past patient stays for easy

reference.

Easy to use, easy to review.

LEGIBLE!!!!


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Q & A


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THANK YOU