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HIS upgrades chart completion services by Sue Pletcher Director, Health Information and Patient Access Services Health Information Services (Medical Records) began scanning all inpatient discharge records on June 29.  The huge undertaking will allow physicians to complete their chart deficiencies online. It also allows for the viewing of these patient records through Oacis. There won't be a need to request ‘old’ records on patients with a discharge date of June 29 or later. Select clinics and inpatient units, emergency department records, and records requested by hospital patient accounting at both MUHA and CMH have been phased into the scanning process for the past year. Physicians in those areas piloted this process and provided valuable input. The advantages of having the paper record scanned and electronically signed are: Immediate access to patient information via Oacis Viewing of record by multiple users at the same time Online signatures to complete medical records from any network computer Elimination of paper reports/transcription being transported throughout the hospital Easy access to medical information for coding and billing processes Ability to audit who has accessed patient information More timely release of information to referring physicians and other authorized requesters Elimination of labor and costs associated with the assembly, maintenance, delivery, and storage of paper records Electronically signed version of the document in Oacis is the final and legal copy Improved control over the issues associated with ‘loose material’ Better security over information stored electronically with elimination of lost records The transition to scanning patient records brings with it a major change in work process for the HIS staff. Employees now focus on preparing the paper chart for imaging, scanning the information, manually indexing all forms not bar-coded and reviewing the quality of the end product for completeness and clarity. When this scanning process is complete, the legal patient record resides within the imaging system. The paper is then logged and placed in a box off-site for destruction in six months. Prepping a record for scanning is not simply taking out staples and tearing pages apart. It's tedious process requiring much attention to detail. All documents in the patient record are: checked for same patient name and medical record number placed in reverse date order (except for the progress notes that are in date order)  verified as present to the extent that can be determined checked for a bar code or create a bar code  examined for tears or folds in the paper and then repaired  reviewed to be certain they are housed only in this system or are removed since information should not be stored in two data repositories.  A header and trailer sheet must be printed for each record so the scanner knows when to start and finish a specific record. The prepping process demonstrates why it is so important to have all documentation associated with the medical record kept together.  The average inpatient chart has 150 pieces of paper and the average number of discharges a day is 80. This results in HIS staff scanning 12,000 documents daily on inpatients alone. Emergency Department records, consents and some outpatient charts are also scanned. Multi-Departmental Project Undertaking a project of this magnitude took a great amount of team work and commitment on the part of the HIS staff, the Oacis team, the CCIT LanVision team and LanVision and Healthscribe vendors.  The knowledge required is so varied and indepth that experts in these different fields are essential. This extensive work is often transparent to the end user—we want it to look easy and be easy to use.  “The access ANYware system is beautiful. This is one of the best electronic advances MUSC has made. It is a real time saver. I can complete all my charts in a third less time,” said Sunil Patel, interim chair, Department of Neurosurgery. Online Chart Completion Editing and signing documents on line brings MUSC a step closer to an electronic medical record. Physicians with incomplete records can log on to accessANYware through the accessANYware icon. Those with questions or wishing to set-up training should contact Christine Lewis at 792-3924 or pager 12597. OnLine Chart Completion Process involves: Enter accessANYware log-in and password Click ‘OK’ at Confidentiality Screen View ‘Pie Chart’ that lists incomplete records Do you want to complete deficiencies? Yes List of record deficiencies is displayed in the Left Column of the ‘In-box’ Review the document carefully and edit as needed Reviewer can return document to HIS staff if incorrectly assigned or to request HIS to complete edits Document can be completed and ‘electronically’ signed Continue on with next record or clear work list and LOGOUT of accessANYware system Friday, Aug. 6, 2004 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. 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