Developing the Electronic Patient Medical Records System

(What Hospital Administrators Should Know)

- Noel D. Lawas MD -

Session Objectives

• Appreciate the breadth of possibilities in customizing what the system can do in support of managing information

• Appreciate the true value of having a fully functional electronic patient medical records system

• Describe tools which can be used to retrieve patient information and perform analysis

At the end of the session, the participants should be able to:

How Patient Health Records Are Linked to Majors Transactions of a Hospital

Simple (Manual) Records Management System

Record FormFiling Cabinet

Reports

• Data written into a record form

• Completed records are filed

• Summary reports produced and printed

Activities Associated with the Handling of Patients Medical Records

• Recordings of Requirements, Observations and Services Given to a patient– Patient Consent– Face Sheet– Admission Record– Clinical History and PE

Findings– Laboratory Exam Results– X-ray Results– OR and Anesthesia– TPR– Doctors’ Orders– Nurses’ Notes

• Patient Registration• Daily Patient Census• Registries

– Birth– Death– Admission– Discharge

• Index– Inpatient– Operation– Disease– Physician

• Hospital Statistics• Quality Patient Records Mgt

Patient Management Medical Records Mgt

Enhancing Simple Records Management System Through Automation IT Techniques

Data Capture Database Mgt System

ReportGeneration

Objectives of Automating Medical Records Management System

• Achieve the highest possible efficiency, given the limitation of resources, in managing patient records– Faster service time– Complete and error-free records– Always available on demand– Increase productivity of hospital staffs– Increase “profit” margin

Limitations of Automating Medical Records Management System

• Cannot take the place of important legal requirements attached to medical records

• Not ideal for qualitative recordings• Details of many services/transactions are

voluminous and very seldom used for management decision-making

• Doctors and nurses have peculiar ways of describing different types of medical information

Common Techniques in Automating Data Capture

• Limiting selection of possible entries in a data field (use of droplist, look-up table, etc.)

• After selecting an entry, related fields are automatically filled up

• Computation is performed after entering the needed set of data

• Use of external devices like bar code reader.

Notes in Automating Report Generation

• Used in generating regularly needed reports by management

• Commonly used forms:– Printed reports– Web reports

• Features– Limited to reports requiring straightforward

calculations and data processing– Requires pre-determined specification of

output information

Supercharging Records Management System Through a Computer Network System

Data Capture

Database Mgt System

ReportGeneration

Computer Network Environment

Data Capture

Data Capture

Advantages of Records Management Under a Networked Environment

• Integrated system of records management – physical barriers disappear

• All records within the system can be linked together. As such, linked records are treated as one (Eg. Useful in pts’ billing)

• Complex reports needing inputs to different sets of records are easily generated.

• All records are readily available to management anytime and anywhere

Example of Integration of Records Management

Charge Slip

(Pharmacy)

Charge Slip

(Laboratory)

Charge Slip

(Radiology)

Charge Slip

(Other Fees)

Charge Slip

(Nursing Srv)Network Server

Example of Using Linked Records to Achieve Greater Performance

Registration Record ~ Admission Record ~ Diagnostic Exam Performed

Name

HIN

Address

PhilHealth

Attending MD

Clin Service

Bed No.

Initial Dx

Date of Exam

Name of Exam

Type of Exam

Exam Fee

Registration Records

Admission Records

Diagnostic ExamRecords

NameHIN

Attending MD

Date of ExamClin Service

Name of Exam

Type of ExamExam Fee

Example of Complex Reports Needing Multiple Inputs

Patient Billing

Statement

Itemized patient’s charges

AccommodationCharges

Charge SlipsProfessional

Fees

Example of Secured High Availability of Patients Medical Records

(Using the world wide web)