Tag: Clinical Documentation

Comes in two forms: (1) Health Information Management that can increase cashflow and improve patient outcomes; and (2) Medical Dictation & Transcription Services where you can access full outsource, co-source or backlog and overflow transcription that is aligned to your needs.

Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

Creating patient-centred clinical documentation through facilitated, digitised and connected solutions

by Lee

The main objective of a clinical documentation solution is to deliver timely, accurate, concise documentation about the patient, to the patient and caregivers.

Operating an effective clinical documentation solution requires engaging a combination of components including, dictating and referring clinicians, administration staff, external recipients, the PAS and EMR, in-house typists, an outsource transcription company and speech recognition.

A digitised solution that is efficient and cost-effective relies on all these components being integrated and accessed easily, simple to deploy and manage, and is housed in a secure and scalable platform in the cloud.

At iMedX we know that hospitals and providers need all these components to operate effectively, whilst being responsive to their needs and strategic objectives.

Striking the right balance

If one of these key components is not considered, the effectiveness of the solution and its ability to meet all stakeholder needs is hampered. It is easier to balance the utilisation of these, while creating a flexible and appropriate solution, if the platform is electronic and secure.

There are hospitals that need to access outsource resources easily, and others that require clinician accessibility and flexible working, ultimately the platform needs to be able to accommodate for all the needs of the users and provide the appropriate integration.

iMedX provides the platform to access these components and integrate with them but gives the provider the power and the control to manage the utilisation of them.

Leveraging the components

The key to providing timely, accurate, concise documentation about the patient, to the patient and caregivers is effectively leveraging the usage of each of the components.

What we commonly see in hospitals is that clinicians need to access speech recognition, as well as outsource transcription; inhouse typists need to access speech recognition; managers need access to an overview of the process and reports to ensure efficiency; everyone needs to access the PAS; and everything needs to end up in the EMR.

At iMedX we believe that the most effective clinical documentation solutions are not achieved through solely utilising just one component, for example speech recognition, but rather connecting them to one another and facilitating the relationships in the most productive, cost-effective way.

Visit imedx.com/au and contact Kath Rawson on 0800 753 250 or nz-sales@imedx.com for more info.

Enabling innovation in the end-to-end revenue journey

by Lee

Healthcare is seeing a new age of innovation. One that brings prospects of a more connected and technologically enabled system with real-time accessibility of care and data. Whilst innovation is heavily focused on delivery of care, the backend operators of our hospitals, including health information and hospital revenue processes are also ready for innovation. The opportunity we see lies in maximising hospital revenue through the end-to-end journey.

The end-to-end funding journey

While health information, finance, and clinical services of the hospital often operate separately, when we piece the revenue journey together, they are all reliant and critical to one another. At iMedX we’re focused on understanding the entirety of the journey from pre-admission to revenue or budget utilisation, finding that at each step best practice is not always obtained due to its reliance on other steps. For example, quality coding relies on accurate and timely discharge summaries which in turn rely on comprehensive and complete records of the patient stay. This means that innovation must take into account every step and its people in order to truly make a difference.

What innovation looks like

Innovation in the end-to-end revenue journey is more subtle than what we see in other scenarios. In this context innovation looks like an interconnected, consistent, and reliable journey that enables each function in the journey to operate at its best. The way we do that varies with each hospital.

Innovating across such a complex journey can be a complicated task. From our experience, there are some core factors that are fundamental for innovation.

  1. Aligned processes and procedures
    To achieve consistency and reliability across the journey, processes and procedures are a great place to start. Most importantly, their alignment in relation to the Health Information Services (HIS), Clinical and Finance departments. There are three (3) things to consider; standardisation which involves clear steps and requirements for staff to follow; adoption, including how staff will implement these processes in an effective way that is inclusive, strategic and does not place any further workload burdens; and governance, starting with suitable training and performance management strategies.
  2. Technology
    In our experience, a challenge the HIS department faces often is operating on an IT system that is outdated. Although IT can be a complex problem to resolve, it is integral to the funding journey operating at its best. Technology in healthcare is improving, however IT systems of the backend operations are being left behind. Investment in the uplift of these systems seeks to improve workflows, productivity and reporting requirements which creates better revenue results and improved clinical care.
  3. The profile of HIS department
    The clinical documentation process is core to the function of coding and ultimately revenue or activity reporting and budget utilisation. The greatest governors over accurate documentation is the HIS department who, too often are overshadowed by clinical and finance departments.The best and easiest way to raise the profile of HIS is to deliver the facts. Analysing hospital data means audit samples can be selected that will provide the key to facilitating and lifting the profile of HIS. This knowledge enables coders and HIMs to approach clinical staff confidently to educate and refine documentation processes that record the care of every patient that is treated.

The iMedX perspective

Each journey offers different opportunities for innovation, iMedX is focused on finding them and helping hospitals to set up their end-to-end journey to maximise revenue opportunity and improve clinical care. Our work aims to uplift and strengthen steps in the process from maintaining clinical coding throughput, auditing for accuracy and helping to promote the highest quality documentation for patient safety, whilst keeping the bigger picture in mind.

Medical Transcription and Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

Co-source Transcription in New Zealand

by Lee Carter

iMedX works in partnership with New Zealand’s DHB’s and we have gained firsthand insight into the cost pressures impacting clinical operations today. We know many DHB’s are operating in a financially challenging environment and are looking for ways to reduce costs and deliver efficiencies.

This whitepaper explores the challenges DHB’s are facing surrounding increasing transcription demand, battling workforce shortages and increasing service costs; provides insight into how Australian hospitals have transformed these same processes using a technology and service enabled co-source delivery model; and presents the ways in which this can impact positively in New Zealand.

Access the whitepaper here.

Medical Transcription and Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

CodeR at Maryvale Private Hospital

by Lee

iMedX delivers a remote coding solution providing a continuous service to Maryvale Private Hospital through CodeR.

CodeR is a streamlined solution enabling end-to-end remote clinical coding & auditing of paper records. The solution utilises proprietary technology CodeR, a secure info input platform that connects to any scanner and a workflow management platform that stores electronic records for Clinical Coders/Auditors to access.

Maryvale Private Hospital is situated in Morwell in Victoria’s Latrobe Valley and services the Gippsland municipalities of East Gippsland, Wellington, Latrobe, Baw Baw, South Gippsland and Bass Coast. With 46 beds, Maryvale is an acute medical and surgical hospital providing a comprehensive range of medical, surgical and consulting services. The hospital has cared for over 55,000 patients since 1991.

Being a regional hospital with paper records, Maryvale Private Hospital historically needed coding staff onsite to complete the clinical coding. In 2020, the hospital had both coders apply for long service leave for extended periods of time. With this challenge and the need for onsite coding due to paper records there was a risk that the coding turnaround time would increase thus interrupting the timeliness of the revenue stream.

Through the iMedX capability to provide CodeR, our HIS expertise, plus continuous clinical coding service, iMedX was able to effectively fulfil the hospital’s requirements.

“On behalf of the team at Maryvale Private Hospital, we’ve really valued the contribution the iMedX team have made through our partnership. The CodeR platform was simple to learn and implement, providing our staff reliable and experienced clinical coding support for the remote coding of our paper records. The iMedX team are able to view the records easily and quickly through CodeR and then enter the accurate codes directly into our PAS. We have also found it especially valuable being able to leverage the experience of the iMedX team to support us with our Coding Auditing and with their knowledge of the Private Health sector funding model. Thank you iMedX team.”  Susan Chan, Finance Manager

See how the CodeR solution works at Maryvale and the outcomes it has delivered here.

Medical Transcription and Clinical Documentation Solutions, iMedX Australia & New Zealand (Health Information Management) imedx.com.au

iMedX Analytics: Transparency in Clinical Documentation

by Lee

Get greater visibility of your transcription volume, turnaround times and productivity with the iMedX  Analytics dashboard – updated automatically!

FIND OUT HOW YOUR TRANSCRIPTION WORKFLOW IS TRACKING

Using our data analytics suite for transcription activity, iMedX Analytics transforms data into actionable business insights delivered through an easy to use dashboard interface. Say goodbye to manual tracking and excel spreadsheets!

You can easily see and understand vital parameters such as volume trends, turnaround times, work types, productivity, and much more all without the need for spreadsheets and manual data analysis. When you are able to understand your clinical documentation operations clearly, the opportunities for efficiency, quality, and revenue improvements are endless.

The dashboard allows you to customise your analytics:

  • Include activity from your in-house typists and iMedX typists and compare volumes,
  • Choose the graph formats you’d prefer to view your data in, and
  • Request reports on whichever measurement option you like.

The dashboard has three sections:

  1. The Volume Dashboard presents many data elements which are essential for making informed staffing, turnaround time, and cost projection decisions. Gain a new understanding of your documentation process with trends by work type, dictator, and jobs marked for review. Dictation issues type can be rapidly identified and resolved. Additionally, the volume dashboard allows you to see your complete transcription situation, including total minutes, total jobs, and averages by time.

  2. The TAT Dashboard tracks turnaround time and delivery of transcription. Quick turnaround times are essential for quality patient care and communication. With the TAT dashboard, you can easily identify current TAT loss related to a number of factors including provider, work type, facility, and more. Filters are available to select the desired date range, dictator, work type, or location for viewing trends in various graph formats. Trends, heat maps, and raw numbers are visible at a glance and immediately provide an understanding of where, when, and why TAT may be suffering.

  3. The Productivity Dashboard provides a complete view of the throughput for both your in-house typists as well as iMedX typists. This dashboard enables you to see broad trends in addition to individualised trends for specific typists. The productivity report is helpful for understanding the productivity of your MT base, which enables you to implement management processes as required.

iMedX Analytics for transcription enables you to understand your dictation to transcription workflow with ease. To set up iMedX Analytics with your iMedX transcription solution email us at sales@imedx.com.au

To find out more information on our dictation and transcription solutions, please send us an email or call us on 1300 727 423.