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Sunday, September 26, 2010
Title: Lessons Learned From Maintaining and Upgrading An Established Perinatal Information System
Discipline: Professional Issues (PI), Newborn (NB), Childbearing (CB)
Learning Objectives:
Submission Description:- Discuss major components of a comprehensive assessment and security plan.
- Identify elements of a discoverable medical record.
- Develop strategies to maintain the integrity of patient records within a legacy system.
The growing sophistication and evolution of electronic perinatal information systems increases the complexity of system enhancements and upgrades. Duke University Health System has continued to be a leader in the use and implementation of the EMR. The current EMR was introduced in 1999 and has gone through five major software upgrades over the past 10 years. Each upgrade provided a unique opportunity for learning and discovery. With over 3200 users and 260 site licenses at multiple sites, we have a unique opportunity to share with our peers.
Medical record documentation currently exists in paper-based and electronic format. The paper-based medical record has been traditionally defined as the legal record. However, with the e-disclosure laws, all electronic documentation is considered discoverable. DUHS like many institutions has approved the designation of pre-defined electronic documents as the legal record, resulting in a hybrid medical record.
In order to maintain the integrity of patient records in a legacy system a comprehensive assessment and security plan must be implemented prior to each upgrade. Examples would include testing & validation, long-term storage of data and installation records, configurations logs, audit trails and system logs. Security plan development must include IT, Clinical, Clinical Practice, HIM, and Risk Management.
The focus of this poster will discuss the key lessons learned from five successful major software and hardware upgrades and multiple system patches within four linked servers. Additionally, the importance of preserving the medical record in various software versions for future review will be addressed.
Medical record documentation currently exists in paper-based and electronic format. The paper-based medical record has been traditionally defined as the legal record. However, with the e-disclosure laws, all electronic documentation is considered discoverable. DUHS like many institutions has approved the designation of pre-defined electronic documents as the legal record, resulting in a hybrid medical record.
In order to maintain the integrity of patient records in a legacy system a comprehensive assessment and security plan must be implemented prior to each upgrade. Examples would include testing & validation, long-term storage of data and installation records, configurations logs, audit trails and system logs. Security plan development must include IT, Clinical, Clinical Practice, HIM, and Risk Management.
The focus of this poster will discuss the key lessons learned from five successful major software and hardware upgrades and multiple system patches within four linked servers. Additionally, the importance of preserving the medical record in various software versions for future review will be addressed.
