Neonatal Notes Manager (NNM) is an innovative software tool used to support the patient documentation needs of a Neonatal Intensive Care Unit. It combines comprehensive clinical data with artificial intelligence and a friendly graphical user interface to assemble patient documentation – all guided by individualized user preferences and templates. NNM was designed by and for clinicians working in the Neonatal Intensive Care Unit.
NNM can operate in two modes. It can support a private-practice neonatologist who simply wants to collect patient data and use that data for the generation of patient notes. Or, it can support a large medical center where all clinical data related to nursing and physician care is collected. This data can be used by medical students, residents, fellows, attendings, and nurses to quickly create patient notes and act as a source for planning, reference, research, and management analysis. In either mode, NNM can help manage the work flow and ensure that tasks such as follow-up exams, daily progress notes, attending review, and billing are completed.
Neonatal Notes Manager significantly reduces the time required to collect data and develop patient notes. The resulting notes are clear, complete and legible. NNM recognizes that each practitioner has their own style and level of detail for developing notes and accommodates those differences. However, the previous work done by other staff members is easily incorporated into the current notes to eliminate duplicate work.
Data collected by Neonatal Notes Manager is used to generate patient documents such as admission notes, nursing flow sheets, daily progress notes and discharge summaries. Letters and reports are also generated to communicate patient status to third-parties, to generate daily sign-out sheets, to generate patient bills, and act as a source for clinical research.
NNM can also be used to plan and track the tasks associated with the ongoing management and discharge of the patient – and helps ensure that critical tasks are not missed. Reminders to complete any type of task (hearing tests, eye exams, immunizations, parental education, state-mandated reporting, etc.) can be created and tracked in
NNM. These reminders can be entered manually or created automatically based on rules established by the NNM user. Through the reminder generation function, a discharge plan can be automatically created based on the clinical status of the patient on admission, and constantly updated as the status of the patient changes.
In sum, the benefits of Neonatal Notes Manager include:
- Central source for clinical data – eliminating duplicate, sometimes inconsistent information
- Reduced time to develop comprehensive patient notes
- Clear and legible notes in a format preferred by the individual clinician
- Improved communication among NICU staff and with third parties such as referring physicians and longterm care organizations
- Comprehensive planning and tracking of tasks required for ongoing management and discharge of the patient
- Rich source of data for clinical research, management analysis, external reporting
- Timely and accurate patient billing
The net result should be improved patient care and a more efficient neonatal intensive care unit.
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Demographic and medical history data for both the mother and infant is tracked. The maternal data includes perinatal history such as medications, complications, risk factors, screens, prenatal care, and delivery details, along with extensive demographic data. Infant data includes demographic data along with detailed information about the birth.
Labs such as CBC, blood gas, bili, blood screen, LFT, electrolytes, medication levels, urine test, toxicology screen, and a variety of cultures can be tracked with multiple entries per day. Infrequent or very unique lab test can also be tracked through the special labs feature. A combined view of lab data is provided that can display all lab results for a particular time period and generate a graphical display of individual readings over that time period.
Diagnostic exams such as head ultrasound, CT scan, hearing test, and eye exam can be tracked with detailed findings and a notation for when the next exam should be done.
System-based physical exams can be tracked using common findings available through drop-down selections.
Free-form text is available along with user-defined selections for findings and typical exam defaults. Prior exams can be copied and modified for current findings. Detailed vital signs are also tracked.
A summary of the day’s fluid/nutrition can be entered that tracks fluids from all sources and automatically calculates and classifies fluid totals and calories. Output detail can also be tracked.
The optional Nursing Module can be used to track the hour-by-hour activities of nursing care. Typical flowsheet data such as IVs, vitals, monitors, intake, output, assessments, nursing care, wound/line care, environment, parent interactions, cardio-respiratory events, and O2 therapy can be tracked. Typical calculations for fluid totals, calories, GIR, and output are done automatically. The nursing data is entered and viewed in the form most commonly used by the nursing staff – the flowsheet. All selections are user-defined and each flowsheet entry is associated with the person who made it. Revisions are tracked and text comments can be entered for any type of data. Nursing flowsheet data can then be automatically retrieved into nursing and physician notes.
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Detailed data on oxygen therapy is tracked from simple to complex. Based on the type of therapy being provided, data is collected on delivery mode, vent settings, and patient status. Delivery modes range from mask, to nasal cannula, to CPAP, to volume or pressure ventilation, to high frequency ventilation. Additional data can be tracked by the respiratory therapist and the combined nursing and respiratory therapy data is stored and displayed in one place.
Patient diagnoses are tracked noting the onset and resolution times and the staff member making the diagnosis.
Patient procedures are tracked noting the staff member performing the procedure, the time of the procedure and the reason for the procedure. Procedure comments can be collected and later used to generate text for an admission note or procedure note.
Ordered medications are tracked and cross-referenced to administered mediations. Medications administration can be done through IV entries and a medication flowsheet.
Computer-based images can be managed and accessed. Patient images with comments can be viewed along with images of people who may interact with the patient.
The clinician builds a patient note by simply selecting, through drag-and-drop, the high-level outline of the note.
The outline of the note can be problem-based, system based, or in any other format preferred by the practitioner.
Based on the outline topics selected, NNM automatically retrieves the appropriate clinical data for inclusion on the note. Additional comments can be added through drag-and-drop selections of frequently-used comments that are specific to the individual practitioner and the current outline topic.
Previous notes can be copied and used as a basis for a current note. In addition, user-defined templates can be used to automatically generate a note outline, or re-arrange an existing note outline. The copy function and use of templates make it even faster to develop a comprehensive note.
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A variety of note types can be generated. For example, an Admission Note can be generated where infant demographic and maternal history are automatically retrieved along with text relating to admission procedures.
Other note types include Medical Progress Notes, Nursing Progress Notes, Consult Notes, Procedure Notes and
Discharge Summaries.
When creating a Discharge Summary, the clinician can direct NNM to review the clinical data from the entire stay and summarize key points such as diagnoses, medications, oxygen therapy and referrals. Also, during the course of the stay, the clinician can mark comments made in daily progress notes as “discharge comments”. These comments can be automatically retrieved and copied into a discharge summary. The end result is that most of the
Discharge Summary is automatically created from the clinical data and note comments that were entered during the course of the stay.
Notes can be written and edited by any authorized staff member. When the note is complete it is “signed” by the staff member. When signed, all text on the note is frozen and cannot be changed or deleted.
Notes can be created by a staff member and reviewed, updated and signed by a different, higher-level staff member.
The final note can be reviewed and printed as a single note or printed as a batch of signed notes for a particular staff member.
Clinical data can be entered into NNM through easy-to-use data entry screens. Data can also be collected through the NNM HL7 interface. This interface can receive data from other hospital systems, in the industry-standard HL7 format, and automatically load that data into the NNM database.
The interface includes functions that receive the HL7 transactions, send acknowledgements that the transactions have been received, validate the transactions, and load the accepted transactions into the database. For example,
NNM can receive HL7 transactions from the hospital’s Admission-Discharge-Transfer (ADT) system to automatically accept patient data for both the infant and mother. NNM can also receive lab data from the hospital’s
Laboratory system and eliminate the need for manual entry of labs.
Data received by the HL7 interface can be used directly for patient documentation or can be augmented manually with additional data that has not have been collected by any other clinical system. The HL7 interface can also be used to transmit data from NNM into other hospital systems.
The NNM HL7 interface is provided and supported directly by Isoprime. Isoprime can also provide extensive implementat ion assistance on the HL7 interface to customize it to each hospital’s unique data requirements. The result is the benefit of working with just one vendor for the NICU software, interfaces, and implementation support.
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The Task Planning and Tracking (TPAT) module in NNM provides reminders for a wide array of tasks that can be tracked in the system. These reminders can be for clinical activities such as head ultrasounds or eye exams, and also for patient management activities such as infant care instruction or CPR training. Reminders can also be generated for follow-up activities such as referral confirmation or submission of reports to the state or other external agencies.
Reminders can be generated manually by individual users and can be targeted for all clinicians, a specific job type
(eg: all nurses) or even a specific user. These reminders can be for pre-defined tasks or can be for an ad hoc task that does not require detailed tracking.
Once a reminder is created, the system will track the status of that reminder. If a reminder is overdue, a number of reports will highlight this fact for NNM users. Also, a real-time indicator on the main patient screen will flash if critical reminders are due or overdue. Once the task for an associated reminder is completed, the reminder is marked complete and is linked to the task that fulfilled it. This means that the user can quickly see what has been done, and view the detailed result of a task that fulfilled a reminder.
In addition to the manual creation of reminders, complex rules can be established for the automatic creation of reminders. These rules are created by the system administrator and can be triggered by a long list of clinical events for the patient. For example, a reminder for an eye exam can be automatically generated for any patient admitted with a birth weight lower than a certain value or gestational age lower than a certain value. An eye exam reminder could also be automatically generated for any patient with certain diagnoses or who are on O2 for more than a specified number of hours. Using the reminder generation function, a discharge plan can be automatically created based on the clinical status of the patient on admission, and constantly updated as the status of the patient changes.
Reminders are a key component of discharge planning. A centralized view of all the discharge planning reminders is also provided. All of the reminders associated with discharge tasks are organized on a single screen for review and tracking. In addition, quick access to the tasks which fulfilled completed reminders is available and minutes of discharge planning rounds can be tracked.
Patients can be listed by whether their daily progress note has been completed, by whether billing has been completed or whether any notes need to be reviewed and signed.
Certain comments within a note can be marked as “plan” items. These items are not only listed under their specific outline topic but also get automatically listed under the Plan section of the note. This consolidates the plan items, if desired by the clinician, into one section of the note for review and follow-up. Plan comments are also automatically included in the daily signout sheet for quick reference.
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As part of the note generation process, the practitioner can identify labs to be completed in the next day. Flags will then be displayed the next day to remind the user that labs are expected.
During the course of a patient’s stay, the clinician can mark comments made in their daily progress notes as
“discharge comments”. These comments can then be automatically retrieved and copied into a Discharge
Summary. When this feature is combined with the clinical data summaries that NNM automatically generates, the development of a Discharge Summary is quick and easy – even for a complex patient with a long stay.
A signout sheet can be generated giving a summary of all patients currently on service. A brief history, along with current fluid/nutrition, O2 therapy, diagnoses, medications, referrals and plans are listed for each patient and can be used for signout, discharge planning or even daily rounds.
Over the course of a hospital stay, referrals can be entered for a patient. Referrals can be made to specific physicians or to organizations such as long-term care facilities and governmental support agencies. Based on the referrals, Referral Letters can be automatically generated at discharge time which are addressed to the referred-to physician or organization and provide infant/maternal background and a brief history of the stay. The referral letters act as cover letters for the Discharge Summary and are another example of tools to aid in planning and in saving time.
NNM includes a number of clinical data views and reports to help answer the questions typically asked in an NICU.
Questions arise such as “How many patients were diagnosed with a particular set of problems over a particular time period?”, or “How many patients were treated with a specific medication or class of medications over a particular time period?”, or “What was our starting census, ending census, minimum, maximum and average census over a particular time period?”. These can all be answered using the built-in data views and reports of
NNM.
Clinical data for a specific patient is also displayed in views and reports. Here are some examples of clinical views:
- The Quick View can be used by the neonatalogist and other clinicians to get an immediate impression of the patient’s progress over the last twenty four hours. Presented in flowsheet format, the Quick View consolidates information about IV fluids, enteral fluids, output, apneas and bradycardias, O2 delivery, and key lab values.
Nursing comments, diagnoses and ordered medications are also easily accessible.
- The O2 Therapy View consolidates detailed information such as O2 sats, FiO2, O2 delivery modes, and ventilator settings with blood gases to give a comprehensive view of the respiratory therapy and the results of that therapy.
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- The Service Stay View provides a quick look at all the services stays of the patient. The initial admission and readmissions are displayed along with any movements between levels of care. Selection of a particular service stay takes the clinician directly to the data associated with that stay.
- Growth charts plot the progress of statistics such as weight, length and head circumference against percentile standards. These charts can be view or printed.
Here are some examples of clinical reports:
- The Notes Log can print a running log of all signed notes for a specific patient over a particular time period. This is an easy way to view the history of a patient or print documentation for surgery, diagnostic exams, or external transfers.
- The Service Stay Summary is a report summarizing the key data related to the patient ’s stay in the NICU. Birth statistics, maternal history, transfers, diagnoses, procedures, medications, and O2 therapy are all consolidated into a report that can be used for planning the discharge or reviewing the stay. This report can also be used as the source for external reporting into Vermont Oxford or state-mandated studies.
Specialized reporting modules are also available. These are typically developed to meet the local governmental reporting requirements of the NNM User. For example, NNM customers in Illinois can take advantage of the
APORS module in NNM. This module produces the “Adverse Pregnancy Outcome Reporting System” report directly from NNM. This complex formatted report is produced based on the rules established by the Illinois
Department of Public Health. The data for a discharged patient is scanned for certain clinical conditions, based on user-defined selection criteria, and a report is produced if required. Even the form itself is generated automatically
– saving many hours of chart review and report preparation. This same structure can be used as the basis for producing government-mandated reports in other states.
NNM provides a wealth of views and reports. However, there are an unlimited number of ways to review and analyze data from a comprehensive database like NNM. For cases where you need to go beyond the built-in views and reports, NNM provides an easy way to use the industry-standard Crystal Reports tool for creation of user-defined reports. Crystal Reports can not only generate complex reports from the database, but can also be used to export data into formats such as Microsoft Excel, Microsoft Work, and PDF in instances where those formats are needed.
NNM provides a read-only view of the database that is available for user-defined reports. In addition, NNM includes a number of sample reports that can be used as a starting point for the development of any report needed by the NNM user. Finally, NNM provides a means for organizing user-developed reports so they can be made available to other NNM users – without the need to have Crystal Reports installed for those other users.
Customized data extracts can also be defined and run by users of NNM. Data extracts for research studies, statistical analysis, or import into external databases can be designed through a simple drag-and-drop process. The result of an NNM data extract is a file built in the industry-standard XML format which can be easily imported into spreadsheets, databases, and statistical analysis programs.
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Billing can be done manually by the authorized practitioner or billing suggestions can be automatically generated.
Bills for admission, daily care, procedures, consults and discharge day management can be automatically suggested based on the age and type of care being provided to the infant. The practitioner reviews these suggestions, makes changes where appropriate and approves the bill. NNM then tracks that billing for the day has been completed.
Bills can be batched together and submitted as a report to the billing office where they are then reviewed and entered into the enterprise billing system.
Detailed biographical and contact information can be stored for each clinician. Information such as specialties, certifications, physician groups, employment agencies, and contact methods can be tracked for physicians, nurses, technicians, and unit secretaries. This eliminates the need for paper contact lists.
Information on all of the organizations that an NICU would work with is tracked. Addresses, phone numbers, departmental contacts and even driving directions can be stored for hospitals, agencies, support organizations and payers. This eliminates the need for paper contact lists.
Medication guideline sheets, in either text or image format, and can saved and referred-to in the course of ordering or administering medications.
The system administrator can setup a help file that is specific to their organization. The administrator can also setup general references which can point to internal documents or even external web sites. For example, a reference to a web-based calculator could be included or a reference to an internal policies document could be setup. Any document or web site that can be viewed with Microsoft Internet Explorer can be setup as a reference in NNM.
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NNM offers a number of tools to assist the organization in complying with the HIPAA Privacy and Security
Standards. In addition to the features noted below, NNM provides a unique information event tracking feature.
This tool allows the organization to store a record of all events related to the release of protected data for a particular patient. Events such as notification of privacy rights, authorized disclosure of information, and requests for changes to the patient record can all be tracked. The other HIPAA-related features are listed below.
Each user has a unique User ID and password. The password is encrypted and cannot be viewed even by the system administrator. Users can modify their passwords as needed.
Each attempted access to the system is tracked. For authorized users, their time of login and logout is tracked.
Unsuccessful attempts to login are also tracked noting the time of the attempt and the reason for the failure.
Reports can be generated to show all system access activity.
Each user has an assigned security level which defines the allowed activities within NNM. Users can be limited to view-only, clinical data edit only, or a master level of full administration of codes and users.
Each user has an assigned job category (e.g.: administrative assistant, medical student, nurse, resident, attending, etc). Signing authorities can be established between these job categories that define which job type can sign a note created by another job type. In all cases, a history of who created the note and who signed the note is kept.
Every record that is entered into NNM is tagged with the User ID of the person who added the data along with the time it was entered. If data is changed, an audit trail record is saved which records the original data and the changed data and also notes the User ID and the time of the change.
After a user-defined time period of inactivity, NNM will lockout entry of data and display a screen that blocks a view of the data displayed on the screen. In order to return to their work, the active user needs to re-enter their ID and password. In key locations, the user also has the option of pressing a button to display the lockout screen in order to block view of patient data if they need to leave their workstation temporarily.
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For a single computer implementation, Windows 2000, XP or Vista is required along with the desktop version of
Microsoft’s SQL Server (SQL Server 2005 Express Edition). Isoprime ships a copy of SQL Server 2005 Express
Edition for single user implementations.
For a multi-user implementation, a Microsoft Windows network is required, comprised of a server running Windows
2000 Server or abo ve and Microsoft’s SQL Server (2000 or above) as the database engine. The server should have at least a Pentium 4 processor with 2Gb of memory. However, a dual-core processor with as much memory as possible is recommended. Disk space needs can vary widely depending on the number and complexity of patients. A general guideline is 15Kb per patient-day if just the physician module is being used, and 225Kb per patient-day if the nursing module is also being used.
The database and optional HL7 interface are the only components running on the server. The server computer and SQL Server software do not need to be dedicated to NNM as long as there is adequate capacity to support
NNM. The HL7 interface can run on the same server as the database or a totally separate machine.
All other components run on the client PCs.
For the client (desktop) PCs, we recommend Microsoft Windows XP with a minimum 1GHz processor and 500Mb of memory. Windows Vista is also supported. We recommend a monitor as large as possible, particularly for nursing charting. The NNM program, and a few temporary files, are stored on the client PC, so some hard drive space is required but is well under 50Mb.
While NNM is an outstanding base for managing the data for NICU patients, Isoprime Corporation recognizes that each customer has unique requirements. As a result, Isoprime offers customization services to modify or add capabilities of NNM to best meet their unique needs.
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