Survey Guide Revised EMRAM Criteria

Transcription

1 Survey Guide Revised EMRAM Criteria Page 1 of 23

2 Table of Contents Introduction... 3 How to navigate to, complete, save, and submit subsections... 4 How to distribute sections/subsections for completion/validation... 7 Diagnostic Imaging System & PACS Radiology and Cardiology PACS... 9 Diagnostic Imaging System & PACS Additional AND Non-DICOM Images Clinical Data Repository Information Security & Governance Mobile Device Management Encryption, Anti-Virus/Anti-Malware, Intrusion Detection & Prevention System, and Security Risk Assessment Reporting Nursing/Allied Health Documentation Computerized Practitioner Order Entry (CPOE) Physician Documentation Closed-Loop Medication Administration Laboratory/Specimen Bar Coding IT Department Profile Existing EMRAM questions to be reviewed Page 2 of 23

3 Introduction This guide provides instructions on how to use the Ontario Hospital Association s (OHA) ehealth survey tool s features (e.g., submitting and distributing subsections) and highlights the new/modified questions which correspond with HIMSS Analytics revised EMRAM criteria. Please note that the last page identifies additional subsections which should also be reviewed before you complete your submission as these subsections consist of existing questions which drive your EMRAM score. If you have any questions or require guidance, please send an to dharel@oha.com. Page 3 of 23

4 How to navigate to, complete, save, and submit subsections Once you click the ehealth Technologies and Applications Survey link on the survey tool s landing page, the main menu identified below will appear. Navigate to Subsection To navigate to any given subsection, click the appropriate section link in the main menu (referenced below). Survey section links Then click the link that corresponds with the subsection you wish to access (shown below). To navigate back to the main menu, click back which is located in the upper left corner of the submenu. Navigate back to main menu Subsection links Completing Subsections Once you navigate to the subsection of your choice, please ensure all questions have been answered before you submit the subsection. Please note that you will not be able to submit the subsection if you have not yet responded to all mandatory fields (i.e., the system will flag all fields which need to be populated). The majority of subsections consist of the components identified below. Page 4 of 23

5 Software/Hardware Installation Question Grid To make an initial vendor/product entry or modify an existing one in the question grid referenced below, click the pen icon located in the right corner of the record. To remove a vendor/product record, click the x icon located in the right corner of the record in question. Once you ve clicked the pen icon to make an initial entry or modify an existing one, you will be able to update the Application Status, Software Vendor, Software Product, Contract Year, and Shared Service fields. Please note that with the exception of Contract Year, all of these fields are mandatory. When you are ready to save your vendor/product entry, click the checkmark icon located in the right corner of the record. To include an additional vendor/product entry, click the Add New Vendor/Product button located in the upper left corner of the question grid. Click to make initial entry or to update an existing entry. Click to include an additional vendor/product entry. Click to remove the entry. Additional Questions Once a status of Live & Operational is reported, please note that related questions may appear under Additional. Please ensure you respond to these questions before you submit the subsection. Page 5 of 23

6 Saving and Submitting Please note that if you do not have the information necessary to respond to all questions in any given subsection, you can save the subsection (i.e., you will not be prompted to populate all mandatory fields when you save the subsection). Click Save if the subsection has only been partially completed. Once all questions have been answered and you are ready to submit the subsection, select the checkbox identified below and then click Submit (the Save button turns into a Submit button once the checkbox is selected). Please note that the Completed By field identifies the user who is logged in (i.e., this field cannot be modified). Save button turns into Submit once you select the checkbox. Select this checkbox once you are ready to submit. Page 6 of 23

7 How to distribute sections/subsections for completion/validation The survey tool includes survey distribution functionality that enables you to submit entire sections or subsections for completion or validation. This functionality is located in the last column of the main menu and submenus of respective sections (please see the Distribute column below). Click mail icon to submit section for completion or validation. To distribute a section/subsection, click the mail icon corresponding with the section/subsection of your choice, and then complete the Distribute a Section form that pops up. If "Validation" is selected on the form, please ensure applicable questions have already been completed, otherwise, the assignee will not be able to update responses (i.e., the subsection will be read-only). If you want the assignee to enter responses, please select "Completion" on the form. Once you click Send, an automated will be sent to the assignee with a link to the section/subsection in question. Please note that this link is unique and will expire once the request has been completed. Specify type of request (i.e. completion or validation). Provide address of recipient and then click Send. Page 7 of 23

8 Please note that the assignee will be asked to provide comments before saving the subsection. The final step requires the requestor to navigate to the subsection in question, review the comments that were provided by the assignee, and then click Confirm (please see the screenshot below). Final step is for the requestor to navigate to the subsection in question and then click Confirm at the bottom of the form. Status of distribution request Please note that the status of the distribution request is identified in the Distribute column of the menu/submenu once the request is initiated (please see the table below for descriptions of the various distribution statuses). The section/subsection distribution process involves three steps: i) the requestor submits the request; ii) the assignee completes the request; and iii) the requestor confirms that he/she has reviewed the updates and/or comments that have been provided. Status Name Validation Required Validation Pending Completion Required Completion Pending Description Request has been submitted to assignee for validation. Assignee has completed the validation request and provided comments for the requestor s review. Request has been submitted to assignee for completion. Assignee has actioned the completion request and provided comments for the requestor s review. Page 8 of 23

9 Diagnostic Imaging System & PACS Radiology and Cardiology PACS Please note that the Diagnostic Imaging & PACS requirements have moved down to Stage 1. If your hospital does not offer some or all radiology/cardiology imaging services, please ensure that Service Not Provided is reported as the Application Status for applicable radiology and cardiology PACS modalities. A software installation question set has been created for each PACS modality (e.g., Radiology Angiography) so that respondents can report applicable application statuses for respective modalities. To minimize data entry, the individual PACS question sets have been prepopulated based on responses that have been submitted in the past. For instance, if Live & Operational was reported in the original Diagnostic Imaging & PACS software installation question set and eight of the PACS modality checkboxes were selected to indicate that those modalities are live and operational, then those eight modalities will show a status of Live & Operational along with the vendor information that was reported (please see the screenshots below for your reference). The remaining checkboxes that were not selected will show a status of Service Not Provided. Please review each PACS modality question set to ensure the prepopulated information is accurate. Prior Diagnostic Imaging System & PACS Question Set New PACS Software Installation Question Sets (Pls review prepopulated data in each of these question sets) Page 9 of 23

10 Diagnostic Imaging System & PACS Additional AND Non-DICOM Images The additional questions that were previously part of the original Diagnostic Imaging System & PACS question set were moved to a new subsection called Diagnostic Imaging System & PACS Additional. Please respond to the new EMRAM questions identified below. *NOTE* If Service Not Provided was reported as the Application Status for all radiology and/or cardiology PACS modalities, then please select No in response to the following questions: Does your hospital provide radiology imaging services? and/or Does your hospital provide cardiology imaging services? Radiology & PACS If Yes is selected in response to Is Radiology Imaging 100% filmless?, an additional question will appear: Is there a link in the CDR/EMR for the physicians to view the Radiology images? Cardiology & PACS If Yes is selected in response to Is Cardiology Imaging 100% filmless?, an additional question will appear: Is there a link in the CDR/EMR for the physicians to view the Cardiology images? Non-DICOM Images The question Are Non-DICOM images stored and digitally available somewhere on the network? has been added to a new subsection called, Non-DICOM Images, under Diagnostic Imaging System & PACS. If your hospital does not use/capture non-dicom images, please select Yes in response to this question (HIMSS Analytics has asked the OHA not to include N/A as a response option for this question). Digital Imaging and Communications in Medicine (DICOM) is an international standard for transmitting, storing, retrieving, printing, processing, and displaying medical imaging information. Examples of images that are generated in non-dicom formats (e.g., PDF, MPEG, JPEG, PNG, and avi) include patient-specific images taken by Wound Care or the emergency department (ED) of injuries that are present on arrival. Page 10 of 23

11 Clinical Data Repository Please respond to the updated software installation question set in the Clinical Data Repository subsection under, Document Management. The additional questions identified below appear once an application status of Live & Operational is reported for Clinical Data Repository (CDR). The question Please indicate which of the following is true to describe your Clinical Data Repository? was included to identify if your hospital is using a single repository or multiple repositories. Please note that if you are using multiple repositories, they must be installed in a way that enables clinicians to seamlessly access orders, results, and images in order to meet the revised Stage 2 requirements (e.g., users do not have to sign into different systems and the patient does not need to be re-selected in each disparate data store). If Yes is selected in response to Does the CDR provide access to laboratory test results, radiology imaging test results, or cardiology imaging test results?, an additional question will appear: The CDR provides access to more than 95% of. If your hospital s CDR does not provide access to more than 95% of any of the test results that are listed, this additional question should be left unanswered (i.e., you will still be able to submit the Clinical Data Repository subsection). Page 11 of 23

12 Information Security & Governance Please respond to the questions identified below in the new Information Security & Governance subsection under, Information Technology & Infrastructure. Security Training If Yes is selected in response to Do you provide Security refresher training for existing users? (Ensure all existing employees with access to the EMR are periodically retrained), you will be asked to identify: i) how often security refresher training is provided for existing users; and ii) the percentage of existing users that have received refresher training within 12 months of their previous training. Business Continuity If Yes is selected in response to Is critical clinical information available to clinical staff during system outages?, an additional question will appear: What critical clinical information is available to clinical staff during system outages? If patient allergies, problem/diagnosis lists, and current medications are not available during system outages, this question should be left unanswered (i.e., you will still be able to submit the Information Security & Governance subsection). Page 12 of 23

13 IT Security If Yes A formal policy is in place and enforced is selected in response to the Physical Access and Acceptable Use policy questions, you will be asked to identify how often these policies are reviewed and updated. Physical Access Policy: A document which stipulates the physical security measures, processes, and access restrictions that must be in place in order to safeguard facilities such as data centers and server rooms, that house critical IT infrastructure, systems, and programs. Acceptable Use Policy: A document which stipulates the constraints/practices a user must agree to in order to access the corporate network/internet. Organizations require users to sign an acceptable use policy before granting a network ID. Additionally, this document contains a set of rules specifying how computers/software/networks may be used. Typically, this document identifies user rights, responsibilities, code of conduct, and examples of unacceptable behaviors. Data Destruction Policy: A document which describes how data storage media (e.g., hard drives) and the data contained therein should be securely destroyed, wiped, or overwritten when a server or device is removed from service and disposed of or repurposed. The purpose of this document is to ensure that patient data stored in retired devices and media are securely destroyed or overwritten. Role-Based Access Control: A policy neutral access control mechanism defined around roles and privileges. The components of RBAC such as role-permissions, user-role, and role-role relationships make it simple to perform user assignments. Page 13 of 23

14 Mobile Device Management Please respond to the new software installation question set in the Mobile Device Management subsection under, Information Technology & Infrastructure. Please note that once an application status of Live & Operational is reported for Mobile Device Management, the additional questions identified below will appear. If Yes is selected in response to Are all mobile devices (owned by the organization) that are in use and operating on the network registered/authorized for use?, then the following question will appear: Can all registered/authorized mobile devices (owned by the organization) that are in use and operating on the network be remotely controlled/wiped if they are lost or stolen? Alternatively, if No (some/all devices in use are not registered-authorized) is selected, then you will be asked to specify which organization-owned devices are excluded (a free text field will appear). If Yes is selected in response to Are all devices not owned by the organization (e.g., BYOD) that are in use and operating on the network registered/authorized for use?, then the following question will appear: Can all registered/authorized devices not owned by the organization (e.g., BYOD) that are in use and operating on the network provide restricted access to patient records and be remotely controlled/wiped of all critical patient information if they are lost or stolen? Alternatively, if No (some/all devices in use are not registered-authorized) is selected, then you will be asked to specify which devices are excluded (a free text field will appear). Page 14 of 23

15 Encryption, Anti-Virus/Anti-Malware, Intrusion Detection & Prevention System, and Security Risk Assessment Reporting Please respond to the new software installation question sets in the Encryption, Anti-Virus/Anti-Malware Software, Intrusion Detection & Prevention System, and Security Risk Assessment Reporting Tool subsections under, Information Technology & Infrastructure. Please note that once an application status of Live & Operational is reported for these applications, the additional questions identified below will appear. Encryption Anti-Virus/Anti-Malware Software If Yes is selected in response to Do you have Anti-Virus and Anti-Malware programs in place on all devices connected to your network?, then you will be asked to identify how frequently the programs are updated. Intrusion Detection & Prevention System If Live & Operational is reported as the Application Status for Intrusion Detection & Prevention System, please ensure to respond to the additional question referenced above before submitting the form by selecting at least one of the response options. Security Risk Assessment Reporting Tool If Yes is selected in response to Does the organization conduct periodic security risk assessments and report the results to the organization's appropriate governing authority?, then you will be asked to identify how often security risk assessments are conducted. Page 15 of 23

16 Nursing/Allied Health Documentation Please respond to the updated software installation question set in the Nursing/Allied Health Documentation subsection under, Clinical Documentation. Please note that once an application status of Live & Operational is reported, the additional questions identified below will appear. For both nurse and allied health professional documentation, you are asked to identify the percent of documentation that is captured electronically from structured templates that generate discrete data and whether this documentation is also live in the ED. Please note that in order to meet the revised Stage 3 requirements, at least 50% of both nursing and allied health care professional documentation must be captured as discrete data in the HIS/EMR. Furthermore, nursing/allied health documentation must be live in the ED. Allied health professionals include clinical professionals and technical staff in departments such as Radiology, Respiratory, Laboratories, Radiology, Nuclear Medicine, Pharmacy, Physiotherapy, Occupational Therapy, Social Work, Speech Pathology, and Dietetics. Positions include: Addiction Workers, Community/Social Workers, Dietitians, Genetic Counselors, Occupational Therapists, Pharmacists, Physiotherapists, Psychologists, Psychometrists, Social Workers (BSW/MSW), Speech-Language Pathologists, Audiologists, Kinesiologists, Recreation Therapists, and Chiropodists. Page 16 of 23

17 Computerized Practitioner Order Entry (CPOE) Please respond to the updated software installation question set in the Computerized Practitioner Order Entry (CPOE) subsection under, Clinical Documentation. Please note that once an application status of Live & Operational is reported, the additional questions identified below will appear. Please note that slight modifications were made to the above referenced question and existing responses were maintained. This question now asks about CPOE usage in the inpatient setting specifically. Furthermore, changes were made to existing response options (i.e. the 26-50% option was modified to 26-49%, and the 51-75% was modified to 50-75%). If you responded to this question in the past, please ensure the current response is accurate in light of these modifications. Also, please note that in order to meet the revised Stage 4 requirements, at least 50% of medical orders for inpatients must be entered by physicians using CPOE. With respect to the question Where is the CPOE system used?, please note that response options were modified to single-select response options and additional response options were included. Due to these changes, existing responses were not maintained. Please note that in order to meet the revised Stage 4 requirements, CPOE must be used in the ED as well; however, there is no usage requirement for orders that are entered by physicians via CPOE in the ED. With respect to the question Is your HIS/EMR capable of reporting the timeliness of scheduled orders and tasks?, the corresponding requirement is for management to have access to capability that enables them to track and monitor clinician order and task timeliness (e.g., the system is capable of producing reports which identify when orders were completed). In order to achieve EMRAM Stage 7, orders must be completed within two hours of schedule, 90% of the time. Page 17 of 23

18 Physician Documentation Please respond to the updated software installation question set in the Physician Documentation subsection under, Clinical Documentation. Please note that once an application status of Live & Operational is reported, the additional questions identified below will appear. Please note that slight modifications were made to the question What percent of physician documentation in the inpatient setting (excluding ED) is captured from structured template physician documentation that generates discrete data?, and existing responses were maintained. This question now asks about physician documentation usage in the inpatient setting specifically, and changes were made to existing response options (i.e., the 26-50% option was modified to 26-49%, the 51-75% option was modified to 50-75%, the % option was modified to 76-89%, and the % option was added). If you responded to this question in the past, please ensure the current response is accurate in light of these modifications. Please note that in order to meet the revised Stage 5 requirements, at least 50% of physician documentation in the inpatient setting must be captured as discrete data in the HIS/EMR. Furthermore, physician documentation must be live in the ED. Page 18 of 23

19 Closed-Loop Medication Administration Please respond to the new question set in the Closed Loop Medication Administration subsection under, Drug Information & Pharmacy Systems. In this subsection, you are asked to identify how technology is used to support your closed-loop administration process for medications, blood products, and human milk. If To verify medication at point of medication administration and/or To verify patient at point of medication administration are selected, you will be asked to identify the percent of medication administrations documented in the EMAR that have a successful medication and/or patient barcode scan. Please note that in order to meet the revised Stage 6 requirements, at least 50% of all inpatient medications delivered at the bedside must be done using the closed-loop administration process. If Yes is selected in response to Are blood products administered in this hospital?, you will be asked to identify how technology is used to support your closed-loop blood product administration process. Please note that in order to meet the revised Stage 6 requirements, at least 50% of all inpatient blood products delivered at the bedside must be done using the closed-loop administration process. Page 19 of 23

20 If Yes is selected in response to Is human milk stored in a communal storage location and administered in this hospital?, you will be asked to identify how technology is used to support your closed-loop human milk administration process. Please note that in order to meet the revised Stage 6 requirements, at least 50% of expressed breast milk delivered at the bedside must be done using the closed-loop administration process if human milk is stored in a communal storage location. Please note that in order to meet the revised Stage 6 requirements, the same closed-loop medication and blood product administration processes referenced above must be available in the ED; however, there is no usage criteria (e.g., >50%) for closed-loop administration processes in the ED. Page 20 of 23

21 Laboratory/Specimen Bar Coding Please respond to the updated hardware installation question set in the Laboratory/Specimen Bar Coding subsection under, Laboratory Information System. Please note that once an application status of Live & Operational is reported, the additional question identified below will appear. If bar coding is not used at the bedside for specimen collection or transfusion verification, then please leave this question unanswered (i.e., you will still be able to submit the Laboratory/Specimen Bar Coding subsection). If Specimen Collection Specimens are bar coded at the point of collection/bed side is selected, then you will be asked to identify the percent of specimens that are being verified/identified using bar coding. Page 21 of 23

22 IT Department Profile Please respond to the updated question set in the IT Department Profile subsection (this fiscal year and last fiscal year) under, Hospital Profile. The questions identified below are not HIMSS Analytics questions; based on member input, these questions were included in order to create visibility into the numbers and types of full-time equivalents who support the IT/IS function or initiatives, and whether or not IT services are outsourced to an external organization. This information will help hospitals and health system partners understand the model of IS/IT support that is being used across hospitals. If Yes is selected in response to Are you outsourcing IT services to a vendor, Shared Service Organization, or another hospital?, you will be asked to identify the organization(s) that you are outsourcing IT services to and whether or not related contracted-out expenses are reported in your Trial Balance submissions (please see subsection Contracted-Out Services in chapter 2 of the Ontario Healthcare Reporting Standards for information regarding contracted-out services). For the FTE question set shown above, please identify the number of FTEs within the IT operating budget, within the IT capital budget, and outside the IT budget who support the IT/IS function or initiatives. Please note that decimals can be entered to reflect resources who spend a percentage of time acting in specific roles, and that 0 must be entered if the budgeted FTE category in question is not applicable. Page 22 of 23

23 Existing EMRAM questions to be reviewed Please note that the existing subsections identified below consist of questions which drive your EMRAM score. Please review responses to these software/hardware installation questions and update your responses, if necessary. Section Laboratory Information System Drug Information & Pharmacy Systems Diagnostic Imaging System & PACS Diagnostic Imaging System & PACS Clinical Documentation Clinical Documentation Drug Information & Pharmacy Systems Drug Information & Pharmacy Systems Patient Registration & Registry Systems Clinical Documentation Subsection Laboratory Information System Pharmacy Management System Radiology Information System Cardiology Information System (*Note* this is now a Stage 1 requirement) Electronic Medication Administration Record (EMAR) Order Entry (Includes Order Communications) Medication Administration Bar Coding Pharmacy Bar Coding Patient Registration Bar Coding Clinical Decision Support System (CDSS) Page 23 of 23