Case Study

Uniform Data System for Medical Rehabilitation (UDSMR) is a not-for-profit organization that was developed with support from the U.S. Department of Education’s National Institute on Disability and Rehabilitation Research.

Prior to 2011, the healthcare industry had no centralized documentation system for patient- care information. With changes in regulations from the Center for Medicare and Medicaid Services (CMS), correct documentation of patient care and other patient information has to maintain compliance. As the industry leader with approximately 70% market share in the medical rehabilitation industry, others in the industry looked to UDS to provide a solution. UDS formed a partnership with Computer Solutions and Software International (CSSI) to create a clinical documentation system for inpatient rehabilitation. Rehabilitation clinicians were also an integral resource in designing the software.

SOLUTION

Based on a long-standing successful business relationship, UDS contacted CSSI for assistance to design, develop, architect and build their documentation solution—UDS-PRO Doc System.

CHALLENGES

  • Challenging documentation management – difficulty in supplying accurate patient care documents to (CMS), if required.
  • Difficulty maintaining uniformity in documenting patient care, and patients’ progress during the rehabilitation process.
  • Difficulty exchanging, integrating, sharing, and retrieving electronic health information (EHI) among internal systems, hospitals and other medical facilities.
  • Creating a new documentation system was a huge undertaking and UDS had limited IT resources and budgetary constraints.

RESULTS:

The UDS-Pro Doc System was designed, developed, architected, built and implemented in an amazing 12 months. This system revolutionized patient documentation in the patient rehabilitation segment of the healthcare industry. Some of the main results are:

  • Easy Access: Smart client application allows users to access the system from any internet enabled computer.
  • Better Compliance: Ease in providing a claim or appeal a denied claim with accurate, easy-to-access inpatient documentation.
  • User friendly: Designed with the help of rehabilitation clinicians for rehabilitation clinicians.
  • Interdisciplinary documentation: Easier for nurses, therapists and doctors together each accessing the same information.
  • User set-up/management: Allows administrator to set up user accounts with customizable and unique permissions for users.
  • Single Repository: Facilitates storage and easy retrieval of patient documentation.
  • Improved efficiency: Designed to interface with other hospital information systems to eliminate duplicate data entry. UDS PRO also has warehousing capability for as much clinical data as a facility requires. The UDS PRO DOC’s design allows it to interface with electronic health records (EHR) and electronic medical records (EMR) systems. Users can add scanned external documents as attachments to case records.
  • Customization of clinical documents.
  • Customized display of pertinent patient information from multiple sources.
  • An Audit Log tracks changes to the entire documentation system, including user access, data changes, and module access.

CONCLUSION

CSSI’s domain knowledge and IT development expertise was instrumental in building and implementing this system. The collaboration between UDS and CSSI revolutionized the way patient information is documented in rehabilitation facilities. This was one of the first electronic documentation systems to be introduced in the healthcare system. It is now standard procedure for hospitals, rehabilitation facilities, clinics, and even private practices to electronically document diagnosis, treatment, and patient care, storing data in single repositories.

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“CSSI really understands the industry’s need for secure management of sensitive data, and how to best design technology to organize, control access, and share that data. We’ve trusted CSSI for over ten years for their domain expertise and reliability. The sizeable market share of subscribers is a testimony to the quality of the product created by this strong partnership.”

Pawel Wieczorek, CIO of UDSMR.

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