Centralized record systems can ease outpatient woes
Careful planning keeps records flowing
Your hospital has purchased umpteen physician practices and added outpatient clinics in heretofore uncharted territories. That may be great for the survival of your health system, but it leaves health information managers with the burden of managing and tracking ponderously thick patient records in a geographically dispersed etwork.
Computer-based systems are the obvious answer. But they are still in their infancy, and the number of health providers that have truly integrated systems is still small. So most managers will continue to follow paper trails in the immediate future.
However, some hospitals have found that a centralized inpatient/outpatient record system can be engineered to move records to where they are needed and keep individual records manageable.
At the University of North Carolina Hospitals in Chapel Hill, the record is separated into "circulating" and "non-circulating" volumes, says Joani Perry, RRA, director of medical information management.
When the unit record containing inpatient and outpatient information grows to more than two inches thick, it is broken into separate volumes. The circulating record contains most of the outpatient record for the previous five years and important documentation from inpatient episodes. "It has all the key documents the practitioner needs to treat the patient," Perry notes.
The circulating record accompanies the patient when he or she is admitted to the hospital and is sent to clinics as needed. It is pulled 48 hours in advance of a scheduled clinic visit or admission. Drivers transport it to off-site locations. The on-circulating volume remains in the medical records department’s storage facility.
Perry says she tries to enforce a strict policy of having records returned the day before an appointment. The policy is backed by a clinic coordinator whose job it is to track down missing charts and pick them up.
Much of the needed information is kept on-line, including discharge summaries, operative reports, history and physicals, lab results, pathology reports, reports from some ancillary services such as respiratory therapy and gastrointestinal procedures, and a lot of the clinic notes, Perry points out. Computer work stations in the clinics allow physicians to enter data directly. Perry is also piloting the use of electronic signatures in the orthopedic units.
The only outpatient coding her staff is responsible for is outpatient surgeries, she says.
The biggest challenge, says Perry, is managing all the loose paper generated by ambulatory care. A hospital continuous quality improvement team is looking at the problem and trying to figure out if documentation already in the computer still must be maintained in paper files.
The Seattle experience
Across the continent, Rebecca Wielick, ART, has developed a similar approach for her patient records at Children’s Hospital and Medical Center in Seattle. Patient records are separated into active and inactive files.
Wielick says each patient has a single medical record with five standing dividers, one each for:
• outpatient/clinic visits;
• lab reports;
• diagnostic data;
• therapy;
• admissions.
Both outpatient and inpatient documentation are filed in this record by type, in reverse chronological order. As the chart grows, irrelevant information is moved to other volumes. Only the "active" chart is sent out.
The department gets printouts from each of the hospital’s 56 clinics three days in advance of scheduled patient visits and pulls those charts. Last-minute additions to the list are pulled as needed.
Data entry at clinics is facilitated because 99% of clinic notes are dictated and later transcribed into the patient’s medical record, Wielick says.
Getting to the core’ of the medical record
While it’s easy to say that the active or circulating record should be reduced to its key elements, it’s often more difficult to decide what those elements are. That is something Elizabeth Miller, ART, a consultant with EJM Associates in Seattle has been thinking about for several months as a consultant to Seattle’s Fred Hutchinson Cancer Research Center.
Miller’s job is to make the outpatient segment of the medical record more user-friendly for physicians, which will enable them to get at key data more quickly. To make medical decisions, physicians wanted a very concise "core" medical record, Miller says.
And even though the physicians are operating in the context of a paper-based record, Miller wants to organize its format in a way that would facilitate transition to a computer-based record.
In the record’s original format, each outpatient segment was separate, with a separate history and physical, nursing notes, etc., for each episode of care. Instead, Miller envisions the paper record as a series of icons that you click on, as you would on a computer. So if you clicked on the "lab" icon, all lab results would be presented consecutively.
Physicians liked the concept, but they thought the actual size of the record was still too great, Miller says. So she is at work again trying to "thin" the record to its essentials.
Working with a user group representing clinical specialties, Miller is seeking to identify the permanent core elements of the record the "icons" that would be clicked on in a computerized system as distinct from those that are core for an episode only. Items that are not part of the permanent core can later be pulled and consigned to an "overflow" chart that does not circulate.
Together, Miller and the group developed a grid identifying all elements of the record arranged by type, such as orders, medications, nursing notes, lab reports, radiology, interdisciplinary notes, clinical summaries, progress notes, outside consultations, advance directives, consents, and miscellaneous.
Within each category, documentation is identified for thinning as:
• permanent core;
• permanent for the episode only;
• most recent;
• most recent two weeks;
• most recent month.
For example, care pathways, a pediatric growth chart, and pathology reports are identified as part of the permanent core. On the other hand, X-rays and EKGs can be removed from the core chart after the most recent month. Stem cell count reports and MRIs are permanent for the episode only.
The consent burden
Another element that can swiftly swell the outpatient record is duplicate documentation. This can happen if documentation is kept on site, while a copy goes into the primary record.
Consent forms can also weigh the chart down. Debate continues about whether physician offices should routinely obtain general admission consents each time a patient visits the clinic or whenever minor procedures are performed.
To some extent, what is required may vary with state laws. Many experts, however, say it is important to have ambulatory care patients sign the same "terms and conditions of treatment" consent form that is required of inpatients.
"Consent allows you to release records," says Jeanne Kistner, RRA, director of health information services at Oregon Health Sciences University in Portland. "It says we will treat you, and you agree to accept the treatment and agree for us to bill your insurance company and provide them with copies of your records."
Kistner says her facility does not require the consent form to be signed for each visit. Instead, the form is signed every six months. Other facilities require a signature at least annually.
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