CENTRAL COAST MEDICAL and DEMOGRAPHICS RECORDS CLEANERS (CCMaDRC)
Manually clean and correctly code all medical diagnoses in general practice using existing medical diagnoses coding systems that practices use in their software including Medical Director, Best Practice, Genie, Zedmed.
Record and update all patient demographics including allergies, drug-adverse reactions, smoking status, alcohol consumption status, marital status, occupation, ethnicity, nationality, country of birth, date of arrival in Australia, languages spoken, emergency and next of kin contacts, family history and gender.
Encourage practices to maintain and continue best practice of consistently and properly coding diagnoses once the diagnoses records are cleaned and correctly coded and continue to update patient demographics as they change.
Patient needs are matched to health care resources enabling government funding and health services' planning.
Easy access to properly coded diagnoses and demographics allows clinical research, education and statistical and epidemiological studies and national reporting.
Easy access to properly coded diagnoses and demographics allows clinical benchmarking, data quality and accreditation.
Easy access to properly coded diagnoses and demographics allows chronic disease management, health screening such as cancer screening, immunisations, medication reviews, sexual health and e-Health.
Easy access to properly coded diagnoses and demographics allows reliable identifying of eligible patients for health programs, identifying patients at high risk of adverse health outcomes.
- Easy access to properly coded diagnoses and demographics allows good business modelling and general practice financial opportunities such as practice incentive payments.
REQUIREMENTS & PRIVACY:
CCMaDRC uses an authentication mechanism that requires a persistent internet connection and we recommend that practices have a broadband internet connection. Patient records are accessed remotely and staff are based at our office at 11 Victoria Avenue, The Entrance, NSW, 2261. All staff members have signed and are bound by the Privacy Act and records will be accessed with the consent of the practice.
All patient information collected and seen at CCMaDRC offices is private and confidentiality of patient information is paramount and must be maintained at all times. The rights of every patient are to be respected. All information collected by this office in providing a health service is deemed to be private and confidential.
CCMaDRC complies with Federal and State privacy regulations including the Privacy Act 1998, the Privacy Amendment (Private Sector) Act 2000 and Victorian Health Records Act 2001 as well as the standards set out in the RACGP Handbook for the Management of Health Information in Private Medical Practice 1st Edition (2002). (Refer Section 6 Privacy and Security of Health Information).
CLEAN UP YOUR MEDICAL RECORDS AND COMPLETE YOUR PATIENT DEMOGRAPHICS
With current medical software, when recording a reason for prescription or a reason for contact or a reason for procedure, you are given the opportunity to either select text entries from the medical software coding system or free-type your own entries. The selections are vast and variable and that has resulted in general practice medical records with a list of uncoordinated, scattered medical diagnoses that are not searchable costing patients' health and costing practices huge losses in money and time. In addition the current medical software allows records to be processed with missing patient demographic information. Various software have been developed to extract data from general practices but the results have been dismal at best as the records are poorly coded or missing information and cannot be extracted resulting in incorrect reflection of the true medical records status. Practice nurses are struggling and wasting time searching for patients with chronic conditions or with risk lifestyles in poorly coded and incomplete medical records causing patients to miss out on proper care and causing thousands of dollars in lost revenue for the practices.
CCMaDRC will use your practice medical coding and demographic system without changing any patient diagnoses records to provide consistent searchable coding and demographics which are fundamental to an interoperable electronic health record. Clean and proper coding provides a consistent means to index, store, retrieve, and aggregate clinical data within the practice and across specialties, hospitals and other sites of care. Clean and proper coding and complete demographics helps in organizing the content of electronic health records systems by reducing the variability in the way data is captured, encoded and used for clinical care of patients and research.
Having clean and proper coding and complete demographics enables the practice to extract essential population health data and reports to best assist practice staff implement and drive process change to improve patient health outcomes.
CCMaDRC provides the tools needed to effectively have diagnoses properly coded and complete patient demographics to manage patient's care and improve practice efficiency using the codes in your current medical software.
CCMaDRC aim to provide the health care sector with a nationally consistent clean and well coded medical record diagnoses and complete patient demographics in order to provide better management, measurement and funding of high quality and efficient health care services. This will provide clinically meaningful ways of relating the types of patients treated by health professionals to the resources required. This will also enable health professionals' performances to be measured by creating a link between the patients treated and the resources consumed for providing those treatments allowing output to be measured, which forms the crucial data for policies on funding, budgeting and setting costs.
Clean and properly coded diagnoses and complete patient demographics enable clinical information to be converted into manageable data categories and diagnoses and records need to be the same across Australia to ensure that all jurisdictions are obtaining and providing information the same way as per the Australian and States Coding Standards.