Emergency Department Information System (EDIS)



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Policy

Emergency Department Information System (EDIS)

|Policy Statement |

Emergency Department Information System (EDIS) is an electronic tool designed to improve operational efficiency by assisting Clerical, Medical, Nursing and Allied Health with the care and management of the patient in the Emergency Department (ED).

All ED’s in ACT Public Hospitals will:

• Operate EDIS

• Use it to track patient attendances, movement and subsequent care in Emergency, thereby

• enabling it to report on activity within an ED. It does this by accessing patient demographics, Medical, Nursing, clinical data and the patient journey

|Purpose |

The purpose of this policy is to provide consistency, accuracy and security in the use of EDIS. It should be referenced when establishing other related documents such as Standard Operating Procedures.

|Scope |

This policy applies to all staff (Administration, Medical, Nursing and Allied Health) that use EDIS in the ACT Public Hospitals.

This policy should be read in conjunction with the associated Standard Operating Procedure “Compromised Data Integrity Escalation”.

|Roles & Responsibilities |

Where hospital, or departmental specific policies and standard operating procedures related to the use of EDIS are required, they will align with this policy.

It is the responsibility of all staff in the ED with access to EDIS to ensure that information entered is recorded accurately, and as close to the activity, as possible. The information entered will be based on documented evidence within the patient’s clinical records.

Data Integrity Escalation

The EDIS System Administrator is required to escalate data integrity issues according to the Emergency Department Information System (EDIS) Compromised Data Integrity Escalation procedure.

All ACT Health staff have the right and responsibility to escalate disclosable conduct, without fear of recrimination, as per the “Public Interest Disclosure Act 2012”. For example, a staff member is deliberately altering triage attendance time which does not match the time recorded in the clinical records.

Security

Appropriate use of, and access to EDIS will be governed by a System Security Plan which is managed by the Chief Technology Officer (CTO). The plan will cover, as a minimum:

|Details of system such as: |Access controls such as: |

|Ownership |Creation |Education and Training |

|Administration |Approvals |Auditing |

|Responsibilities |Monitoring |Accountability |

|Data Stewards & Custodians |Removal | |

Training

Staff who require access to EDIS must complete mandatory role-specific training.

Data Validation

If a user recognises the need to edit information in EDIS, the system will log this change. When a person enters an amendment to any existing data, a validation window/box will appear after they have made the edit. The user will be required to enter their own unique password and the reason for the change. Once this is completed, this information, and the user’s name, is recorded in the audit history log.

EDIS System Administrators are authorised to edit specific data according to local Standard Operating Procedures.

Data validations are monitored by Performance Information with a weekly report sent to specific Executives and System Administrators.

|Evaluation |

Outcome Measures

• Accurate, consistent, secure and timely recording of the management of patients who attend the ED.

• 100% completion of mandatory training

• ED Validation Errors per hospital < 1%

• System Security Plan is kept up to date and current.

Method

• ED Validations Errors (Performance Information Portal – ED Live)

• Daily EDIS Auditing Reports

• CHHC EDIS Audit Log Report

|Related Policies, Procedures, Guidelines, Frameworks, Standards and Legislation |

Policies

Data Quality Policy

System Security Plan: EDIS – Emergency Department Information System

Data Release Policy

Procedures

Canberra Hospital & Health Services (CHHS) Emergency Department Information System (EDIS) Data Validation

Information and Communication Technology Resources: Acceptable Use

Strategies

Information Management Strategy 2015-2016

Standards

ACT Health Admitted Patient Activity Data Standards

Legislation

ACT Health Records (Privacy and Access) Act 1997

Electronic Transactions ACT 2001

Territory Records Act 2002

Public Interest Disclosure Act 2012

|Definition of Terms |

ACTH Australian Capital Territory Health

ACT Public Hospitals

For the purposes of National Health Reform public hospital funding arrangements, ACT Public Hospitals are made up of the following public hospitals and service providers:

• Calvary Public Hospital

• The Canberra Hospital

CHHS: Canberra Hospital & Health Services

CPHB: Calvary Public Hospital Bruce

Data Validation

Is the process of ensuring that a program operates on clean, correct and useful data

Data Integrity

Refers to the accuracy and consistency of data stored in a database, data warehouse, or other storage facility

EDIS System Administrator/s refers to the following:

• CHHS: EDIS administrators

• CPHB: Calvary ED Data Manager

Disclosable Conduct

As per the Public Interest Disclosure Act 2012, disclosable conduct means any of the following:

a. conduct of a person that could, if proved:

i. be a criminal offence against a law in force in the ACT; or

ii. give reasonable grounds for disciplinary action against the person;

b. action of a public sector entity or public official for a public sector entity that is any of the following:

i. maladministration that adversely affects a person’s interests in a substantial

and specific way;

ii. a substantial misuse of public funds;

iii. a substantial and specific danger to public health or safety;

iv. a substantial and specific danger to the environment. Note Taking detrimental

action is a criminal offence.

Disclosure Officer

1. A disclosure officer for a public interest disclosure is any of the following:

a. for a disclosure that relates to an ACTPS entity

i. the commissioner; or

ii. the head of service; or

iii. the auditor-general; or

iv. the ombudsman; or

v. the head of an ACTPS entity; or

vi. a person declared under subsection (2) for an ACTPS entity;

b. for a disclosure that relates to a Legislative Assembly entity—

i. the clerk of the Legislative Assembly; or

ii. the auditor-general; or

iii. the ombudsman; or

iv. a person declared under subsection (2) for a Legislative Assembly entity.

1. The head of a public sector entity must declare at least 1 person to be a disclosure officer for public interest disclosures for the entity.

2. A declaration is a notifiable instrument.

System Administrator

A system administrator is a person who is responsible for the upkeep, configuration, and reliable operation of computer systems; especially multi-user computers, such as servers.

|References |

ACT Auditor-General’s Performance Audit Reports:

• Emergency Department Performance Information, Report No.6/2012

• Integrity of Data in the Health Directorate, Report No.5/2015

Public Interest Disclosure Act 2012

|Search Terms |

Emergency Department Information System, EDIS, Data Validation, Data Integrity, Escalation, Tampering, Manipulation, Public Disclosure, Disclosure Officer

|Attachments |

Nil

Disclaimer: This document has been developed by Health Directorate, ACT Health/Strategy & Corporate/Performance & Information, specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

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