TrakCare Solution Guide

Section 2: TrakCare Modules

2.2 TrakCare Foundation CIS (Clinical Information System)

Consider the problems that arise when an elderly, confused patient presents for treatment and is unable to recall past medical experiences. Imagine if the doctor could immediately access that patient’s complete medical history, all from a single screen. Diagnosis and treatment could be carried out much faster and far more accurately. This is what TrakCare Foundation CIS offers.

All TrakCare functionality is built on the Electronic Patient Record (EPR) and allows the capture, display, and analysis of patient-centric information, facilitating better patient care. TrakCare Foundation CIS delivers the core functionality required for clinical patient management.

TrakCare Foundation CIS allows authorized healthcare professionals to review and document patient care. Diagnostic procedures, treatments, consultation records, and observations are entered into the patient’s EPR. Data can be entered, displayed, and accessed using the full range of documentation and display options provided by TrakCare.

Electronic orders and results management are key features of TrakCare Foundation CIS.

TrakCare Foundation CIS can be implemented as a stand-alone product integrated with existing systems, or in parallel with one or more TrakCare modules. When installed with other TrakCare modules, Foundation CIS is fully unified.

Foundation CIS Functionality

All clinical functionality starts with the TrakCare Foundation CIS and includes:

• EPR and MPI (refer to sections 2.1.1 and 2.1.2, respectively, for details)
  
• Clinical Summary
  
• Care Provider Workbenches and Worklists
  
• Care Documentation
  
• Order and Result Entry and Communications
  
• Observations and Graphing

TrakCare Foundation CIS

2.2.1 Clinical Summary

• Clinical Summary provides a summary of clinical and administrative activity when a patient is discharged or transferred to another service. It is used to communicate with consulting clinicians and other caregivers involved in the patient’s treatment.

Clinical Summary includes the following features:

• Configurable Format and Content can be designed (using third-party reporting tools) to meet a range of clinical settings. Patient information provided in the report can include data already available in the existing patient record, such as principal diagnosis, other conditions and complications, procedures, medications, clinical opinion, and management plans. Structured free text can also be added. Data flagged for inclusion in the summary can be flagged as clinically significant if desired.
• Multiple Document Types support different types of summaries, including for inpatient discharges, inpatient or aged-care transfers, or nursing discharges.
• Multiple-Episode Summaries can be produced for one or more episodes, including non-discharged episodes, statistical discharges, and statistical re-admissions. Episodes can also be identified as not requiring a summary.
• Clinical Summary History allows the clinician to view previous clinical summaries (including discharge) generated for a patient. This can be viewed in text or tabular form.
• Referrals, both internal and external, can be created using TrakCare Clinical Summaries. HL7 is used for messaging between TrakCare and the recipient system.
• Automated Distribution of the Clinical Summary includes electronic transfer, automatic faxing, printing, or emailing to the recipients selected by the user. The distribution list includes external healthcare professionals. Clinical Summaries can be automatically distributed to internal and external individuals and organizations using the designated preferred contact method.
• Security Features ensure only authorized users can modify the Clinical Summary. Flexibility exists to retain previously created discharge/transfer/ clinical summaries and produce new versions, which can then be updated.

2.2.2 Care Provider Workbenches and Worklists

Clinician Workbench

TrakCare Clinician Workbench provides functionality to locate, view, and manage patient details as well as manage the electronic charting of the patient’s progress. It allows authorized healthcare professionals to document care and enter treatment and investigational requests directly into the patient’s EPR.

Clinician Workbench includes the following functionality:

• Clinician Priority Workbench helps care providers manage workload from a single screen, by providing summary views of all pending commitments, outstanding tasks and new and important information for patients directly under their care.
  
  A Monthly Calendar provides information about booked appointments, a daily diary view provides lists of appointments, operating theater sessions, events to attend, tasks to complete, and multidisciplinary team bookings, and a quick links section informs the clinician, at a glance, about key data to attend to (e.g., outstanding orders, unread results, and pending discharges can all be actioned).
• Worklists allow healthcare professionals to define and create lists of frequently accessed patients or episodes for quick reference. Worklists available include patient and episode favorites, as well as orders and results.
• Clinical Pathways allow clinicians to define the tasks required for the care of a patient with a particular diagnosis or reason for referral.
• Patient Consultations and Assessments provide a streamlined way for clinicians to quickly document all aspects of the consultation process, including diagnosis entry and planning.
• Care Plans support the planning of care tailored for the individual. Interventions derived as a result of care planning are matched and scheduled into the clinician’s diary. Standard Care Planning templates can be created.
• Legal Record Report provides the ability to generate, at any time, a PDF report based on the patient and clinical information recorded in a patient’s EPR. This functionality meets the need of providing a paper copy of a patient’s EPR for legal purposes or providing a patient or care provider with a print out of the patient’s EPR. The amount of information captured in a report is configurable.
• Editable Letters are an important means of communicating with patients, care providers and healthcare organizations. TrakCare Editable Letters allow sites to set up templates containing preformatted blocks of standard text and patient, episode, waiting list, or appointment related information already stored in the patient record can be retrieved and inserted automatically into the letter when it is created making it much faster to complete. Users can preview a newly created letter and change or add further information as needed prior to printing.
• TrakCare Message Notification is an internal messaging system that allows users of TrakCare to communicate with each other. An icon displays to notify when there are Trak messages waiting for the clinician. Unread and urgent messages are flagged and messages can also be automatically generated as a result of decision support conditions being met.

Nurses Workbench

TrakCare Nurses Workbench helps nurses track and manage their daily workloads, improving efficiency and patient care. Nurses Workbench clearly defines daily nursing interventions and tasks.

Nurses Workbench includes the following functionality:

• Workload Tracking enables nurses to build patient-centric worklists according to various filtering criteria such as specialty, care provider, patient type, patient location, orders and results status, and priority.
• Medication Administration displays medications and fluids that are ordered for the patient. The workbench clearly displays what needs to be administered and provides a streamlined process for recording the administration of those medications.
  
  Medication Administration includes the following:
• Ability to administer any type of medication (Oral, IV and PRN) from the Nurse Worklist and from the EPR Clinical Profile
• Barcode Point of Care Medication Administration provides a simple and quick workflow to assist nurses minimizing adverse drug events by utilizing barcodes to positively identify a patient, identify a medication dose, and validate them both against a current active and matching prescription
• Dual authentication of the medication administration is supported
• Some of the details that can be recorded or viewed as part of the administration include:
• Addition of progress notes
• Medication batch number selection
• Administration of skin test and recording or outcome
• Viewing order notes, PRN notes and pharmacy instructions
• Entering administration status, actual quantity administered and site of administration
• Observations allow the recording of a patient’s clinical observations throughout the episode of care. TrakCare allows clinicians to enter patient measurements such as weight, heart rate, and blood pressure directly into the EPR.
• Specimen Collection allows the viewing and collecting of specimens as required for ordered laboratory tests.
• Nursing Handover provides a flexible way of supporting the consistent and accurate sharing of important patient information between care providers during transition of care between shifts for inpatients and emergency patients. The handover includes assigning care providers (nurse and/or doctor) and displaying pertinent information in patient-specific handover screens and multiple patient lists.
• Medication Chart provides a consolidated view of the general medicines ordered and administered for a patient.
• Clinical Pathways allow the clinician to define the tasks required for the care of a patient with a particular diagnosis or referral reason.
• Care Plans support the planning of care tailored for the individual. Interventions derived as a result of care planning are matched and scheduled into the clinician’s diary. Standard Care Planning templates can be created.
• Scanning and Image Association allows document and image files to be linked directly to a patient’s episode of care or to selected order items.
• TrakCare Message Notification is an internal messaging system that allows users of TrakCare to communicate with each other. An icon displays to notify when there are Trak messages waiting for the nurse. Unread and urgent messages are flagged and messages can also be automatically generated as a result of decision support conditions being met.

Worklists

• Patient and Episode Favorites Lists allow healthcare professionals to add regularly accessed patients or specific regularly accessed patient episodes to a defined list for quick reference.
• Care Provider Patient List allows clinicians to build lists of current patients according to their specifications based on various filtering criteria, such as specialty, care provider, patient type, and patient location.
• Orders and Results Worklists deliver current laboratory, radiology, and medication data to the point of care. Order lists provide the foundation for recording and communicating information about the tests, results, and treatments for each patient. The Results list allows the clinician to access patient results online and review orders according to specified defaults and sort criteria, such as the action taken when the result was reviewed. A clinician’s own specific defaults and preferences can be defined and saved.
• Task List allows care providers to manually define non-order item tasks that are required to be performed. These tasks can be assigned to the logged on care provider or to other care providers. Tasks can relate to a specific patient or to the completion of non-patient-related activities.

Example: Clinician Workbench

2.2.3 Care Documentation

• Consultation delivers care providers a highly flexible and comfortable means of recording the details, clinical notes, tasks, or actions required to complete a patient consultation while minimizing the amount of navigation required. Information captured during the consultation will contribute to the overall EPR as well as be stored against the individual consultation. TrakCare Clinical Consultation functionality provides clinicians with the ability to:
• Review previous consultations
• Create a new consultation manually or from an appointment
• Amend, add, or remove text from a consultation
• Securely edit a previous consultation
• Review a patient’s EPR during a consultation
  
  During a consultation, care providers can, from one single screen, complete the following:
• Add free text consultation notes using a SOAP structured format (subjective, objective, assessment, planning)
• Add consultation notes using the canned text library or pre-configured text templates to assist the clinician in completing the necessary documentation faster as well as prompting for the types of information to record
• Add actions to the consultation, where an action represents typical steps or tasks the care provider may typically choose as part of patient management (e.g., perform a physical examination, record allergies, place an order, or write a prescription)
• Access other EPR chart pages using quick add links for the less frequently completed care tasks
• View the consultation log that includes all actions taken during the consultation and is sortable by SOAP type, date, or consultation category

Example: SOAP Consultation

• Clinical Pathways allow the clinician to define the tasks required for the care of a patient with a particular admission diagnosis or referral reason. The clinical pathway guides the clinician through the patient care phase using site-defined, standard protocols. Routine orders and tests are automatically entered into the patient’s care plan. The clinician can follow the progress of patient care by viewing the assigned clinical pathway, and adjustments can be made to the plan if necessary. Clinical Pathways are developed and managed by the organization and are useful in setting standards of care.
• Care Plans support the planning of care tailored to an individual. Interventions derived as a result of care planning are matched and scheduled into the clinician’s diary. The system allows for the creation of standard Care Planning templates. A care plan can be assigned to a patient on the basis of an assessment. Care Plans also includes the automatic integration of the required interventions as determined in the care-plan formulation.
• Clinical Notes allow the clinician to create case notes and classify them according to type (e.g., Theater Notes, Diet Notes, and Progress Notes). The categories are site-definable. The display of Clinical Notes in the EPR is configurable and searchable.
• Flexible Data Entry options are available for different types of care documentation including image annotation, coded data entry, canned text data entry, free text data entry, voice recording, document scanning and storage, and numeric data entry using manual or calculated fields.

2.2.4 Order and Result Entry and Communications

TrakCare facilitates a proactive approach to care delivery via extensive Order and Result functionality. Order and Result Entry tools and views are the basis for recording and communicating information about order, test, result, and patient care decisions in an efficient and effective manner.

TrakCare Order and Result functionality delivers online, real-time patient data at every point in the care process. With TrakCare, clinicians are not tied to paper charts to provide care and evaluate results.

Order and Result Entry and Communications include:

• EPR Order and Result History presents the order and result history of diagnostic and investigational procedures.
• Order Entry captures relevant clinical information while minimizing the need for manual data entry. Order Entry can display default information for each specific request. Flexible order entry points are provided, including from the main menu, from the EPR order profile, from clinical pathways and from the consultation workflow.
• Order Favorites are frequently requested items displayed for quick selection during the order entry process. Lists of order favorites may be defined at the region, organization, location, group, or individual user level. Order favorites can be restricted to display based on age and gender criteria. This makes it easier for care providers to select order items from their favorites lists when their patient falls into a particular gender or age category.
• Order Questions can be defined to display at various points in the order entry workflow, ensuring relevant clinical information is always collected. Answers to questions can default from previous entries or display relevant pathology results. Expiry limits are available for previously answered questions to help ensure that up-to-date information is being provided.
• Order Questionnaires are order-specific assessments or forms that can be attached to any item being ordered. They can automatically display as part of the order entry workflow or be accessed from a link providing flexible data options but ensuring that key information is captured in a practical and timely manner.
• Order Sets enable healthcare professionals to quickly order a group of items, rather than selecting each individually. An example of this is a standard order set for a patient presenting with chest pain. This set could include various blood tests, an ECG, a stress ECG, and a chest X-ray.
• Order Entry Alerts are triggered for combinations of events including:
• Allergy warnings
  
• Duplicated order warnings
  
• Age/sex restriction warnings
  
• Additional checks that can be defined by the organization
• Orders Requiring Review are the ability to identify orders that require review by approved care providers (e.g., an experimental drug, a very expensive or dangerous drug, prior to being administered). Such orders are automatically placed on a special ‘for review’ worklist with a status that prohibits order execution. Only authorized care providers can complete the review.
• Order Security Restrictions limit the user’s ability to order items and view sensitive orders and results based on security group assignment. Audit trail functionality is available on all parts of the ordering process. Restrictions also include the ability to change the status of an order, the types of order status available to a user, and the ability to discontinue an order based on its status. Order Status access restrictions can vary by the type of order being placed, making it possible to very securely control the type of actions that can be taken. For example, a junior doctor may be able to discontinue or change the status of a previously authorized order for a radiology procedure but may not be able to do the same for a previously authorized order for pain management medication.
• Result Entry is achieved in TrakCare in a variety of flexible ways. For example, TrakCare can receive results electronically from departmental or external systems via HL7 or directly from any TrakCare module. Results can include data captured in a questionnaire (user-defined form), dictated and transcribed documents, observations, and atomic data such as laboratory results.
• Results Display includes clinical indicators such as abnormal results, reference ranges, and criticality status where applicable. Alerts indicating abnormal and new results via system-based highlights and icons are provided. Unread results are clearly indicated, and the audit trail includes not only the reader, but also anyone who has viewed a result. Results can be displayed in a singular or cumulative format and may also be defined to display in a graph.
• Result Forwarding allows one care provider to forward a result along with an accompanying message to one or more care providers simply from a link available against the result. The message can be marked as urgent and recipients can view the results through a link in the message, add comments, and reply to the sender.

2.2.5 Observations and Graphing

Observations allow the recording of a patient’s clinical observations throughout the episode of care. TrakCare allows clinicians to enter patient measurements such as weight, heart rate, and blood pressure directly into the EPR. Values entered as observation items can be used in simple or complex calculations to derive a score for the set or observations being tracked (e.g., a Modified Early Warning Score (MEWS) for emergency services management or simple Body Mass Index (BMI)). Measurements can be graphed to show changes over a period of time and can be printed if required. Abnormal results can be highlighted when they fall outside organization determined reference ranges. The observations may be defined to suit the clinical requirements of the site or users, and can be accessed from the EPR or from the nurses’ worklist or other functional workflow. Comments may be entered against any observation.

Pre-defined and ad hoc graphing functions are available. Interactive graphs can be defined, allowing clinicians and nurses to enter values directly against the graph. Graphs can be embedded in a TrakCare EPR chart or accessed from a link. Reference ranges, (including non-linear), color coding, linked values, tool tips, and charting of variables on multiple axes are supported.

TrakCare graphing functionality also includes the ability to display clinically contextual information as overlays on a defined graph. For example, a graph of laboratory INR values and patient vital signs can have overlays showing the medications that the patient has been taking over the graphed period (e.g., Warfarin, as well as any procedures the patient has had). This helps the clinician interpret the graphed data relative to other aspects of the patient’s management. Links to defined graphs can automatically display based on the patient’s clinical condition or active medications. Calculated observation values such as Body Mass Index and Fluid Balance Totals can also be graphed with fluid balance input and output values displayed in a histogram format.

Example: Vital Signs Observation Chart

Example: Vital Signs Observation Graph

 

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