Sphaira | Enterprise Resources CARE

Electronic Medical Record

Sphaira | Enterprise Resources CARE, information system fully empowers Physicians and Nurses to provide high-end quality of care in LEAN processes to the patients.

Electronic Medical Record is a systematized system designed to accurately collect patient's health information in digital format periodically. It eliminates the need to track down patients' previous paper-based medical records and assists in ensuring data are accurate and legible. It can reduce risks of data duplication and decreases risk of missing paperwork.

These electronic medical records are distributable through enterprise-wide information systems connected through a network or other network and exchanges.
EMRs consist of patient's data demographics, medical history, medication, allergies, immunization status, laboratory test results, radiology images, vital signs and billing information.

EMR Adoption Model
Scoring Hospital EMR Adoption Model

• Enabling healthcare reformation by using information technology, Healthcare Information Management System Society (HIMSS), has developed a methodology and algorithms to score the hospital EMR Adoption Model (EMRAM). The stages of the model are as follows:

1. • Stage 0: The organisation has not installed all of the three key ancillary department systems (laboratory, pharmay, and radiology).
   • Stage 1: All three major ancillary clinical systems are installed (i.e., pharmacy, laboratory, and radiology).
   • Stage 2: Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for reviewing all orders and results. The CDR contains a controlled medical vocabulary, and the clinical decision support/rules engine (CDS) for rudimentary conflict checking. Information from document imaging systems may be linked to the CDR at this stage. The hospital may be health information exchange (HIE) capable at this stage and can share whatever information it has in the CDR with other patient care stakeholders.
   • Stage 3: Nursing/clinical documentation (e.g. vital signs, flow sheets, nursing notes, eMAR is required and is implemented and integrated with the CDR for at least one inpatient service in the hospital; care plan charting is scored with extra points. The Electronic Medication Administration Record application (EMAR) is implemented. The first level of clinical decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/ food, drug/lab conflict checking normally found in the pharmacy information system). Medical image access from picture archive and communication systems (PACS) is available for access by physicians outside the Radiology department via the organisation's intranet.
   • Stage 4: Computerised Practitioner Order Entry (CPOE) for use by any clinician licensed to create orders is added to the nursing and CDR environment along with the second level of clinical decision support capabilities related to evidence based medicine protocols. If one inpatient service area has implemented CPOE with physicians entering orders and completed the previous stages, then this stage has been achieved.
   • Stage 5: A full complement of radiology PACS systems provides medical images to physicians via an intranet and displaces all film-based images. Cardiology PACS and document imaging are scored with extra points.
   • Stage 6: Full physician documentation with structured templates and discrete data is implemented for at least one inpatient care service area for progress notes, consult notes, discharge summaries or problem list & diagnosis list maintenance. Level three of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance alerts. The closed loop medication administration with bar coded unit dose medications environment is fully implemented. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximise point of care patient safety processes for medication administration. The "five rights" of medication administration are verified at the bedside with scanning of the bar code on the unit does medication and the patient ID.
   • Stage 7: The hospital no longer uses paper charts to deliver and manage patient care and has a mixture of discrete data, document images, and medical images within its EMR environment. Data warehousing is being used to analyse patterns of clinical data to improve quality of care and patient safety and care delivery efficiency. Clinical information can be readily shared via standardized electronic transactions (i.e. CCD) with all entities that are authorised to treat the patient, or a health information exchange (i.e., other non-associated hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients in a data sharing environment). The hospital demonstrates summary data continuity for all hospital services (e.g. inpatient, outpatient, ED, and with any owned or managed ambulatory clinics).

Evaluation and Management Services Guide
Medical Records Documentation Guidelines

• Clear and concise medical record documentation is critical to providing patients with quality care. Medical records chronologically report the treatment a patient received and are used to record pertinent facts, findings, and observations about the patient's health history.
• Medical record documentation assists the physicians and other healthcare professionals in evaluating and planning the patient's immediate treatment and monitoring the patient's healthcare over time.
• Principle of medical record documentations for all E/M services is appropriate:Hospital can decide the level of clinical documentation start with Problem Focused until Comprehensive as follows:
  • The medical records should be complete and legible.
  • The documentation of each patient episode should include:Past and present diagnoses should be accessible.
    • Reason for the episode and relevant history, physical examination, prior diagnostic test results.
    • Assessment, clinical impression or diagnosis.
  • Appropriate health risk factors should be identified.
  • The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

1. • While documentation of the Chief Complaint is required for all levels, the extend of information gathered for the remaining elements related to a patient's history is dependent upon clinical judgment and the nature of the presenting problem.
     • Problem Focused – Include performance and documentation of 1 – 5 elements in one or more organ system(s) or body area(s).
     • Expanded Problem Focused – Include performance and documentation of at least 6 elements in 1 or more organ system(s) or body area(s).
     • Detailed – Include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements. Alternatively may include at least 12 elements in 2 or more organ system(s) or body area(s).
     • Comprehensive – Include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements.

Clinical Pathway
Standard Protocol or Procedures

• Clinical Pathways, also known as care pathway, critical pathways, integrated care pathways or clinical guidelines are tools used to manage the quality in healthcare concerning the standardization of care treatments. The implementation will reduces the variability in clinical practice and improves outcomes.
• Generally clinical pathways refer to medical guidelines or evidence base reports.
• Clinical pathways are mandatory required for local or international accreditation.

Clinical Workflow Management
Improve Efficiencies and Productivities through Sophisticated "LEAN" Workflow that Streamline Clinical Processes

• Sphaira workflow management system includes a rules-based module that manages all clinical tasks across the hospital to completion to ensure that the right task is completed by the right person at the right time – driving high-quality, productive care delivery processes.
• Processes can be easily adapted to allow for evolving needs while providing detailed information to measure and help improve their efficiency.

Clinical Documentation
CMS or SOAP

• Physicians are in control as to what and how to archive the process. Some physicians are happy to continue the clinical documentation using S.O.A.P as free-text style, beside that Sphaira will allow for fully-definable questionnaire templates with content-management style start from chief complaint, patient history of illness, review of system, past-family-and/or-social history, attending notes and other supporting information body diagram, dental, children growth chart, CHD risk, fetus growth chart, differential diagnosis, final diagnosis, integrated notes and discharge summaries.
• Leveraging content management capability, external clinical documents are scanned and integrated into the patient's medical record ensuring easy access to important information.

Clinical Charts and Alerts
Presentation in Charts is often as Important as the Information Itself

• Sphaira includes a customizable and integrated specialty-specific charts, improving the quality of patient care by empowering care professionals with comprehensive, easily accessible information for making patient care decisions. Patient demographics, integrated notes, problems, medications, allergies, vital signs, past medical history, immunizations, lab tests and radiology reports are included within the charts.
• Taking advantage of the structured data and decision support, Sphaira provides actionable alerts that direct the care professional to the specific matter at hand and let them resolve it immediately.

Computerized Physician Order Entry
CPOE is a key of Increasing Patient Safety and Quality of Care

• Sphaira enables orders to be entered directly by Physicians. To facilitate efficient data entry and allow for standardization of order sets, Sphaira provides an intelligent, fully customizable user interface. Paperless orders and results reporting are possible for all ancillary services such as laboratory, radiology/imaging, blood bank, pathology as well as orders for nutrition, procedures and patient monitoring.

Medication Management
Enhance Patient Safety through electronic Prescribing, Drug Dispensing, Drug Administration and Documentation

• Sphaira fully supports the management of medication lists as well as drug prescribing. Through integration with third-party drug databases such as MIMS, Sphaira offers real-time clinical decision support such as duplicate therapy warnings, drug-drug and drug-allergy interaction checking as well as access to clinical information at the time of decision-making.

Clinical Risk Factors Assessments
CHD, CAP PIRO, APGAR, FCS, GCS, BPU, ...

• Clinical Risk Factors Assessments are tools to measure the patient's present condition at the point and compared with previous measurement. As of now, Sphaira is already imbedded with Activity Pulse Grimace Appearance Respiration Score, Community Acquired Pneumonia PIRO Score, Four Coma Scale, Glasgow Coma Scale – Pediatric and Adult, Braden Pressure Ulcer Risk, Cardio Heart Disease Risk, Fall Risk—Pediatric and Adult.

Nursing Care Management
Improving Nursing Documentation and Care Plan

• Sphaira includes tools that allows nurses to better manage their workload, facilitate care planning and focus on making the right care decisions, all of which provide more time to interact with patients. Patient observation and monitoring, data entry, care planning and task scheduling are supported while built-in regulatory and administrative reporting enables nurses to focus on improving safety and patient care.

Operating Theater Management
Documentation Surgery Procedures

• An Operating Theater is a specialized facility of the hospital where life-saving or life improving procedures are carried out on the human body through invasive methods under strict aseptic conditions in a controlled environment by specially trained personnel to promote healing and curing with maximum safety, comfort and economy.
• Operating Theater Management, managing of multiple types of processes groups for Inpatient, Outpatient, Emergency, ICU and Walk In.

1. Surgical Reservation & Scheduling
   • Define operational hours for individual OT, duration of operation category, patient reservation and surgery team.
   • Provides RCCP workload (capacity versus load).
   • Provides APS scheduling work list.
2. Operating Theater Process
   • Pre-Operative
   • Intra-Operative
   • Post-Operative
3. Operating Theater Analytical
   • OT Cost vs. BPJS
   • OT Standard vs. Actual (duration time)
   • OT Efficiency

Medical Check Up & Medical Test
MCU Personal and Corporate

• MCU/MT is a kind of medical procedure performed to detect, diagnose or monitor diseases, disease processes, susceptibility to prevent mechanism that can be done to avoid dissatisfaction and losses caused by sudden health problems.
• There are many type of health check up defined such as:
  • Medical Test.
  • Medical Check Up – Personal.
  • Medical Check Up – Corporate.
• Hospital with their available facilities can develop the standard or customize package for MCU or MT, which consist with physical examination, laboratory test, and radiology examination and so on, off course with special pricing strategy.
  • Medical Check Up – Personal
    • One or a small group of people with own pretention joins MCU on-site hospital with or without appointments and at the end of results, receive MCU Reports.
  • Medical Check Up – Corporate
    • This type of MCU typical collaboration between hospital with company with customize test menu and conducted on-site or off-site hospital.
    • In the system, treat as project MCU bases to cover:
      • Data Management.
      • Define Business Rule Management
      • Define Departments Fit/unfit
      • Compile and Review MCU Results
      • Provide MCU Report for individual participants
      • Provide MCU Summary Data and Report for Corporate evaluation.
      • Corporate Invoicing and Settlement
  • Medical Test
    • Corporate's personnel recruitment to identify the Fit/Unfit at the position required.

Patient Safety and Quality Care
Ensuring Patient Safety and Quality Care as a Top Priority

• Sphaira delivers numerous features such as checklists, standardized treatment protocols called Clinical Pathway, clinical decision support system and warning alerts to improve patient safety and quality care. Identification mechanisms like RFID and barcode enable positive identification of patients, lab specimens, medications and devices to prevent most common errors while at the same time providing audit trails of the tasks performed.

Privacy, Security and Confidentiality
Providing Disclosure While Respecting Patients' RIGHTS

• High quality healthcare requires individuals to share sensitive personal information with their doctors and other healthcare professionals enabling them to make the most accurate diagnoses and provide the best treatment. Sphaira ensures that this information is kept confidential at the time of entry, storage and exchange by providing authentication, encryption and access control at every level. Privacy levels prohibit access to most sensitive information without additional clearance. All data entry, update and access is logged and audited and full compliance to patient consent is enforced.