INPATIENT
AND EMERGENCY SERVICES DOCUMENTATION:
AUTOMATION AND NETWORK IMPLEMENTATION
ANIL MITRA, 11/21/2005. PRINTED 2/16/2006
This document first outlines an automated treatment planning system and appropriate agreements related to its use. The current system, described under ‘current installation,’ is available for installation. This is followed by possibilities for further development. Some possibilities would be easy to implement; more ambitious ones would require planning / design and significant investment of resources.
Features / benefits:
Appearance and efficiency. Appearance and readability are improved. Efficiency: when a new plan is opened date and time are pre-entered; name of patient must be entered; data fields to be entered may be highlighted; staff names are entered once. Master plans and subsequent admissions require only modified information to be entered. Staff suggestions re problem statements (next item) etc. may be easily implemented.
Medical necessity. Problems are selected from a drop-down list or customized. The options encourage formulation in terms of medical necessity: a typical plan would have two psychiatric problems – reason for hospitalization and underlying cause based in an (approved) mental illness.
Password protection. No current archival; continue to use hardcopy; changes may be penned; optionally any changed page (of 3) may be re-printed
Training / documentation
Requirements for implementation
Consult with medical / social services / nursing staff regarding medical necessity, drop-down list and other features above. Consult with social services / nursing regarding convenience of entry and use. Signatures: I am hoping that sw/at staff will enter their interventions. The easiest solution to the problem of signatures that then arises is to have all signatures, including the patient’s, on a separate page. Testing – in use by select staff; modify as indicated. Consult with IS regarding directory to store, networking; disk space; implementation of security features; number of plans open at a time. Time: 8 – 16 hours to implement; additional time for minor modifications.
Agreement
Mental Health right to use and engineer the software is unrestricted. No further explicit or implied rights. The technology is my is my property.
A formal arrangement would be required for work on Level I and II and ‘other’ developments.
The resources required for Level I developments will be in proportion to amount of change to be implemented; benefits are immediate.
Examples of Level I Developments
‘Intelligent’ automation. The main Level I development is the implementation of simple forms of ‘intelligence:’ the interface would ask the user questions (later questions being selected according to previous responses) and suggest problems, goals, interventions etc.
Re-design of automation and user interface. The current system has evolved from a primitive form and further development would benefit from comprehensive design and re-implementation. Incorporate suggestions, learning from experience. The system stands to benefit from work on the user interface. Incorporate tutorial. Miscellaneous developments. (Underlining indicates additional documentation.)
Special purpose planning. Develop, incorporate, save special plans for high profile, resource intensive clients; interface with OP and other planning.
Archive plans. Add date / time stamp. Logging?
Level II is higher level automation. The resources required for Level II developments may be extensive; benefits would be long term.
Level II Automation
Example: ‘automate the automation’ for forms. That is, Level II automation is code to write code that can be applied to changes or other forms
Example: implement as database for flexibility, integration and control
Example: automate installation. Placed here because the benefit would not be immediate
Example: Implement policies / procedures / guidelines online in web (html) format; organize for ease of access.
Example: Orientation / training manuals – MHW, RN, MD… The MHW manual exists in primitive online form. It might, in terms of getting everyone on the ‘same page,’ be useful to integrate these manuals.
Example: Forms design, automation and linking – implements efficiency, may be deployed to eliminate redundancy and incorporate experience (‘intelligent’ forms); database implementation for greater flexibility, integration and control…
Example: SV / PES Home Page that would link to policies, forms, orientation, memos, communication log, useful mental health related links both local and on the Internet… This would be very easy to do and would help enhance coherence and focus of care, documentation, and administration
Example: A variety of research topics organized around provision of inpatient and emergency services.