Larkin Community Hospital (LCH)

Larkin Community Hospital (LCH)

Introduction

Larkin Community Hospital (LCH) is a private health facility with low budget

The goal of LCH is to comply with new healthcare regulations in obtaining Electronic Health Records

LCH has inefficiency in documentation which poses risks such as medical errors

Its recommended to adopt the MEDHOST clinical applications

The electronic health record is a new technological method of storing and managing medical data. Medical practitioners can capture the patient medical history and make effective decisions. EHR helps to improve quality of care as it avoids risks such as medical errors.

Situation

LCH is planning to outsource options for EHR systems

This will provide accurate, safe and revenue documentation

There are several cases of missing clinical information

The facility revenue records cannot be accounted for due to lack of records

LCH is on paper documentation for both clinical and material needs for patients

Data management is inefficient at LCH. The hospital revenue records cannot be traced, which creates the risk of loss. Lack of evidence on clinical information not only risks the lives of patients but also jeopardizes the quality of care.

Dangers faced with paper documentation

Its time consuming to retrieve data from the files

It’s prone to errors

The storage is not scalable

Lack of back up

No security

It’s difficult to retrieve patient data history

LCH is facing a big challenge with old and analogue documentation methods. The physicians take a long time to retrieve relevant data from the files. The documents pose the risk of insecurity as anyone can easily access them. LCH needs to develop strategies to be liable to patients and increase the quality of care provided. This can be achieved through the use of the EHR system.

Purpose of SBAR

To focus on the specific impacts of managing the revenue and financial aspects of adopting MEDHOST for clinical documentation.

Background information

LCH uses tri-fold printed forms for documenting clinical information

The physicians record data on the progress notes

The hospital policy requires the nurses to document equipment usage and supply dispensing in their patient care notes (PCN)

The nurse care plan is documented on limited index cards

The current system of documentation is not efficient and reliable. The production of documents is tedious and require physicians to fill several sheets. However, there is no guarantee that the information documented will be lost or misplaced.

Assessment findings: Patients

The patient registration is done on Rolodex

The handwriting is done on wrist bands for identification of patients

The numbers can be smudged, and accounts will be unrecognizable

There is a risk of patient safety because the physicians cannot identify the patient and their information to treat them effectively. Therefore, there is a high probability of making mistakes.

Assessment: Nurses

Nurses are leaving out detailed documentation where the hospital is unable to bill for services

Nurses forget to get back to the specific pages to reassess findings that can be billable.

No alert for the nurses which can be provided by MEDHOST EHR care.

Improper documentation negatively impacts the billing process because there is no evidence to ascertain the transactions.

Cont’d

Poor documentation of devices such as air mattress usage

Documentation was placed after placement of air mattress which should happen before

Nurses could not determine how long the patient required the mattress

Nursing interventions, e.g. inserting IV and Foleys, were documented poorly, and in some instances, it was not documented at all.

Lack of proper documentation raised several charges. The revenue and supply are lost because of simple mistakes. Nurses could not retrieve and use data in making medical interventions. The errors made risk patient health safety.

Assessment: Physicians

Key ICD coding was not appropriately used since the physicians could not recall the correct code.

The handwriting was difficult to decipher

Essential patient information was being missed by nursing and ancillary staff

The assessment of physician notes proved that patient care was at risk. The handwriting was invisible, and the nurses could not clearly understand the information.

Cont’d

Paper entry and ancillary orders, e.g. respiratory therapy was delivered and not billed

This was due to poor documentation of the performance of the order

The lab was referencing orders through slips that most of them were not legible

Reporting was done through Matrix and placed in the patient chart, which was damaged, dirty and lost.

The failure of physicians to bill the orders caused effects on revenue collections. Poor documentation, such as damaged and dirty orders, affected information delivery.

Recommendations

LCH should consider opening a Clinical Informatics Department

There should be two Informaticist specialized in clinical skills for EHR building and teaching

MEDHOST should provide onsite training on building MEDHOST coding.

LCH should incorporate the IT department to provide floor computer equipment

Recommendation: Modern technology

Nurses should have “workstation on wheels” and physician desktops at specified workstations

IT will purchase appropriate servers for data transcription and interfaces from MEDHOST to Lab report devices and radiology film systems.

WIFI Network with closed DNS will be efficient for data security and HIPAA compliance

Fiber network should be used.

Implementation

After building MEDHOST, Super Users should be identified in every department for referencing

End-User training should kick-off to train staff

MEDHOST will provide go-live assistance with company super users

The ancillary interfaces should be properly installed and tested to ensure efficiency

MEDHOST patient care benefits

Nurses can document diagnosis accurately

Nurses can document the status of equipment used, e.g. Wound Vac

Patient care planning will be electronic and easy to track actual billable nursing intervention regarding IV/Foley Insertion

Easy management of orders, i.e. identification of pending orders and follow-up

Respiratory can adequately document the assessment

Application of MEDHOST strategies will make work easier for nurses. It will reduce making mistakes because patient records are accessible. The billing process will be efficient, which provides for accountability.

Benefits to the LCH

Easy to track and bill physician-patient encounters

Quick notes about bedside procedures will utilize ICD-10 coding

Physician order entry will be 100% electronic

LCH will benefit from the transition to into electronic documentation. The billing process will be efficient, providing accurate records of revenue.