Archive for the ‘Electronic Medical Record’ Category

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Progress, Change, Future

January 22, 2012

The future of healthcare information systems and a career in healthcare informatics holds exciting opportunities for healthcare organizations. Many improvements will be made in current technologies available. Although the concept of the electronic medical record (EMR) has been around for quite some time, we are just starting to see some advances in the actual implementation of automating portions of the patient medical record. To get to a fully automated health record, where all aspects of the legal medical record communicate to all systems, seems like a daunting task and yet so exciting to be a part of during these times. A career as a healthcare informatics professional will continue to be a desired profession and will gain momentum in the value these professionals will bring to an organization. Identifying their roles and responsibilities will become unique to each organization’s needs. Because of the many abilities and knowledge of healthcare informatics professionals, one healthcare facility may utilize these professionals in a different way and environment than another facility. Perhaps if there is not a developed informatics department, these professionals may even have different reporting structures based on where the organization sees them contributing and fitting into the organizational chart for that particular facility. The healthcare informatics field of study will be fundamental to bridging the gap between Information Technology Departments, Administration, clinical staff, physicians, vendors, and end-users. These positions are knowledgeable in a vast amount of areas, such as: information literacy, human computer interaction, human factors, usability testing, project management, working as change agents, standardizing language, evidence-based healthcare, numerous types of computer software such as database systems and spreadsheets. One cannot argue the fact that these knowledgeable individuals have developed skills, which bring much value to an organization. If these positions are utilized, directed, and supported, they will be extremely beneficial within a healthcare facility. Implementing, supporting, and maintaining an EMR is progress for any organization. The power of progress is amazing and builds upon each generation’s knowledge. Suppose each new generation had to rediscover numerals or language or medicine. The world would see no progress. Each generation stands on the shoulders of the previous generation to reach higher. Therefore, change is the price we pay for progress, and the EMR will bring about change for healthcare organizations. Change itself is not progress; it is the price we pay for progress. We will see some of the most advanced technology and the quest for a fully developed electronic health record will begin to take hold. As generations replace older generations an environment of automation will be expected and accepted by healthcare consumers and healthcare providers.

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Posted in Electronic Medical Record, Employment Opportunities, Future of Information Systems, History & Future of Healthcare Informatics, Standardization | Leave a Comment »

Head to Toe Examination and Documentation

January 11, 2012

Completing a thorough head to toe assessment is a skill that takes practice and a broad knowledge base. No body system stands alone. Completing a quality assessment of one system may lead to clues about issues or problems in another system. Although head to toe exam is recommended, it is important for clinicians to develop methods that work for them. Patients may present with acute symptoms or complaints that do not allow time for a comprehensive exam. It is vital for the nurse to be able to discern what level of assessment is required for each individual. A patient who is in obvious distress will require a much focused assessment and relatively quick intervention. The type of assessment can also be affected by the health care setting. Nurses working in an outpatient setting may have more time to complete a comprehensive exam and history. Nurses working in hospitals may have multiple patients with various problems that require focused assessments for the sake of efficiency. Some may have a modified head to toe examination technique. Documenting assessment findings have been greatly facilitated in the facility for which I am employed. Each patient room is equipped with a computer to allow for immediate entry of assessment findings. All units have at least five to six, computers- on-wheels (COW) that can be taken from patient to patient if needed. It is interesting to observe the level of competence exhibited by nurses. Novice nurses tend to take copious notes on each system while more experience nurses can gather much information about his or her patients during the general survey. As assessment skills develop, nurses can gather information with minimal effort.

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Posted in Computer Charting, Electronic Medical Record, Health Assessment | Leave a Comment »

The Impact of HIPAA on Patients and Nursing Staff

August 9, 2011

When HIPAA (Health Insurance Portability and Accountability Act) was passed in 1996 it was an important step in providing a patient with new rights to privacy, greater access to and control of their medical records. This was made necessary due to the increasing practice of electronically sharing data by fax and computer. Had this not passed we would probably be checking our medical records on “Youtube”.

 

However, as with all good things, there is usually a downside. There was great confusion understanding just to whom, when and how patient information could be shared. This interfered with doctors obtaining necessary information from other medical professionals when a timely response was critical to patient safety.

 

The stiff penalties associated with non-compliance also generated some fear in the medical institutions. Civil penalties of $25,000, in addition to fines of up to $250,000, and 10 years in jail was pretty frightening.

 

Much of this confusion and fear has diminished in the last few years as far as the medical profession is concerned.  However, patients are another matter.  As I discovered from a quick survey of family and friends, it appears that nobody actually reads the forms that they receive and sign. Most have a vague idea that it involves privacy, but have no idea of the implications.

 

Until a situation arises, most family members do not realize that they cannot access their adult children and sibling’s medical information without written consent of the patient. Even fewer realize that there is an expiration date to the consent form.

 

This misunderstanding results in many heated telephone conversations, particularly with parents of adult children.  These parents want to set up appointments and get test results and do not realize that they are not entitled to this information. This can be a great distraction and time waster for the nursing staff.

 

How can we do a better job at educating patients and family with respect to HIPAA?

 

Perhaps some of the problem with HIPPA can be summed up in a joke that appeared on hippa.yale.edu in 2004.

 

Knock, Knock.

Who’s there?

HIPAA

HIPAA who?

Sorry, I am not allowed to disclose that information.

 

 

 

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Posted in Electronic Medical Record, Healthcare Informatics Protection | Leave a Comment »

Reduce our national debt by reducing the federal electronic medical records mandate, comment

July 21, 2011

Your post Reduce our national debt by reducing the federal electronic medical records mandate is right on target. The federal government and President Obama should not be mandating electronic medical records in the way they propose. The medical/nursing community and hospitals know what is best for themselves and their budgets.

I will add that hospitals should pull the reigns on electronic medical records. What I see is fierce competition between hospitals to draw patients. This competition occurred with CAT scans, MRIs, helicopter ports, etc. Just because one hospital in town has the latest item, does not mean the other hospitals in town should follow suit. Sure, time and saving lives are critical things to consider. The money spent could be used in providing some basic and needed items for rural hospitals. This includes providing the personnel needed for some of the rural hospitals. Our rural hospitals have a greater need than our city hospitals.

Original Post
July 11, 2011

Reduce our national debt by reducing the federal electronic medical records mandate

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Posted in Electronic Medical Record, Standardization, The Impact of Informatics on the Sociocultural Environment of Health Care | 3 Comments »

Foundations of an EHR

July 21, 2011

Identifying current processes, paper and electronic forms, (clinical decision support tools), and workflow processes is the foundation to building an effective EHR. When an organization manages its forms, paper or electronic, it manages its processes. Many forms are necessary for collecting and documenting patient information. Unfortunately, most organizations do not see the value of managing these documents. Whether for electronic or paper, forms management includes the design, creation, revision, and obsolescence of these decision support tools. Maintaining proper version control is essential to meet the current standards of documentation dictated by regulatory agencies and the organization itself. Standardizing forms used throughout the healthcare facility plays a large role in helping the clinical staff to know what data to collect and document which forms are available, and where to access them. This facilitates the delivery of proper patient care. Additionally, standardization saves costs not only in the production of the form, but also in the use of the form. Forms management does have an effect on patient safety and the quality of care. Proper forms management can greatly assist the development of an EHR. Understanding existing forms and processes is necessary for developing accurate electronic processes in the EHR. Before an EHR is implemented a disaster recovery plan must be defined. This plan must identify the paper forms required for use. These paper forms must continue to meet the requirements of creation, revision, version control, and obsolescence to meet the ongoing needs of the current documentation processes. It is necessary to have correct, backup paper data collection tools for clinical and business operations to continue. Often a forms analysis, which documents the current state, is a first step in migrating to an EHR. This is extremely valuable for an organization to know its current used forms, volume, costs, workflow, and production information. This enables the organization to make future decisions based on this information. If a bad process is not identified before automating it, one now has a very expensive bad process. Assessing the current forms management environment can significantly decrease this risk and increase the effectiveness of the EHR and guarantee its successful implementation.

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Posted in Electronic Medical Record | 5 Comments »

Reduce our national debt by reducing the federal electronic medical records mandate

July 11, 2011

I agree that electronic medical records (EMR) that help to save lives, reduce paperwork, reduce expenses, and secure healthcare information. Larger vehicles like SUVs can also save lives and secure passengers. But, this does not mean that every family or business needs to trade in their fuel efficient smaller cars for larger SUVs. This is more true when these families and businesses are struggling during this economic recession (or depression).

Our government can save money by not currently dealing with the EMR mandate, by not tying up our court system with this mandate and letting our hospitals spend this money within their communities (meaning the government does not have to put extra money into these communities).

President Obama, this is one way of reducing your stress, the legislators’ stress, the courts’ stress, and the stress of the American people. Relieve our nation of the current EMR mandate. Consider a revised and later mandate.

Thank you.

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Posted in Electronic Medical Record, Standardization, The Impact of Informatics on the Sociocultural Environment of Health Care | 6 Comments »

The Importance of Health Assessment, comment

May 25, 2011

The quantity and quality of nursing charting can be improved by using Computer On Wheels, or an electronic hand-held or similar device. Your health assessment skills will definitely take a turn for the better.

Original Post
March 3, 2011
The Importance of Health Assessment
As a seasoned nurse I think I perform a pretty good assessment. However, reading the first four chapters of our textbook and doing the first lab exercise has reminded me about a basic concept that in our fast pace world we tend to loose sight of. That is the concept asking open ended and non-judgmental questions and then listening to the answers and asking follow up questions. Today’s healthcare environment doesn’t allow for much time but I realize I can better utilize the time I have by improving my assessment skills of asking questions and listening more to the answers I receive.

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Posted in Electronic Medical Record, Health Assessment | 5 Comments »

Importance of Skin Assessment in Elderly and Child Abuse, comment

May 17, 2011

This is one area where healthcare informatics can be of great help. Instead of nurses trying to remember what to assess and what to write down, the health electronic record will indicate what assessment needs to be done and documented. If the nursing and hospital administration wants skin assessment done, they can include it in the program. And they can set the computer program to indicate to the nurse when this assessment should be done. Thus, the nurse does not have to guess in most circumstances.

Another part of the medical electronic record is the use of cameras. Some camera systems are able to insert an image of the skin assessment directly into the electronic chart. This is a huge time saver for of all nurses. No more writing essays on what was seen on the patients skin.

Original Post
October 18, 2010
Importance of Skin Assessment in Elderly and Child Abuse, comment
Skin assessment is a more valuable tool than we give it credit or time for. There are so many clues to a long list of health issues; from the varience in color, turgor, texture, temperature and thickness, to hair distribution, and condition of the nails. All of these variances from norm could be linked to some health issue. Issues like nutritional deficiency, allergy, local or systemic disease; such as melanoma or systemic lupus erythematosus; or they could be signs or the ‘remnants’ of abuse.

Unfortunately, I don’t think the nurse on the floor routinely gives skin assessment the time or attention needed to pick up on these clues. The most opportune time to find these signs would be on admission, during the initial assessment. What I see on the floor, is short staffing more often than not, trying to care for more patients than can be fully cared for during their shift, and bed shortages, requiring ’quick’ turnover. I am also afraid that the gains in my staffing numbers over the past year are in jeopardy with the reforms and cuts in reimbursement that I think are coming. Thorough assessments are an essential part of health care, of preventative medicine, and all of our professional practices; so I truly hope there will be the time and ability going forward to complete this valuable task.

Original Post

May 26, 2009

Title: Importance of Skin Assessment in Elderly and Child Abuse

In studying skin assessment, one cannot help feeling overwhelmed. Without a desire to pursue dermatology, the unlimited amount of skin lesions, pustules, macules and papules can lead one to skim over information out of the pure necessity for mental sanity. The mind can only hold so many pictures at once. However, I do see the need to ensure the memorization and ability to recognize and diagnose normal skin variations. In reading articles and working with children and the elderly, one unfortunately sees the reality firsthand of physical abuse and neglect. This can often be recognized by assessing the skin. Breakdown, malnutrition, physical abuse, bruises, injuries at different stages of healing can all be noted by a thorogh assessment of the skin. As follow up care and the big picture should always be a part of our thought process in nursing assessment, the ability to note whether a skin assessment finding is simply normal or abnormal is vital to our practice.

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Posted in Computer Charting, Electronic Medical Record | 52 Comments »

When Will Technology Catch Up

December 9, 2010

The age of technology has made great strides in the medical profession, improving the care of patients and in many ways making bedside nursing more efficient.  I began my nursing career in the mid 1970’s, everything was done on paper, the lab would come and draw blood at 6 o’clock in the morning to tell us what a person’s blood glucose was for insulin coverage prior to the bedside glucose monitors we now have.  The younger nurses that I work with love to hear about the “old days when” from myself and other nurses who have been around for more than a decade.

As we go through our daily work week we have cat scan, x-ray, lab draw results continuously flowing through our computers, usually available within an hour of a patient being tested, allowing for further testing and treatment decisions that use to take up to 24 hours or longer for doctors to accomplish, are now accomplished during a single shift.

From Monday to Friday information flows smoothly most of the time, but then it is the weekend and it seems that time reverses and we are in another era.  This past weekend was my weekend rotation, I recall one patient in particular that was hoping to go home, his discharge was going to be determined by the results of  an echocardiogram that was done early Saturday morning.  His cardiologist came in at 1 o’clock, no report was available within the computer or when cardiac testing was called.  Sunday came and went, Monday morning the man was discharged.

This scenario was seen more frequently prior to the technology now available to us,  however it needs to be available seven days a week to give the best care possible and save money, the weekends need to catch up technologically with the Monday through Friday work week.

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Nurse charting in the hospital setting: Does electronic charting win? (comment)

November 29, 2010

We recently started electronic charting in the ED and it has been a challenge for all! One of the biggest pros in our ED are the decrease in patient complaints of never seeing a nurse or doctor. Our computers are stationary at each bedside so nurses are more visible and available for patients and families. It is so simple now to view patients charts without hunting down paper charts. Downtime is a problem but one that we are getting more accustom to.

Original Post
August 13, 2010
Title: Nurse charting in the hospital setting: Does electronic charting win?
Two years ago my hospital transitioned to electronic nurse charting. Adapting this new form of documentation caused a rumble amongst much of the staff. It seems there is always a natural fear that arises when something so new in form is implemented. At that time I had only been a nurse for a little over a year, so I was open to just about anything as I was not too set in my ways. I continue to hear the occasional comment reflecting back to the good ol’ days when charting involved nothing more than a pen and paper. Last week our computer system was out of service for three hours for upgrades and as I was charting, once again on paper, I began to contrast and compare the two different styles of documentation in my mind.

Electronic charting has many benefits. It’s legible, finite, organized, and consistent. For example, intake and output are entered and it automatically gives the nurses and doctors a net positive or negative daily fluid balance. With paper charting we had to painstakingly calculate intake and output hourly, which is basic math, but still remains time consuming. Patients’ lab values are automatically uploaded to their e-chart which also saves time. Vital signs automatically flow from the bedside monitor to the e-chart and simply need confirmation to be permanent. No longer are the days of placing triangles and dots for graphical depiction of vital signs.

There are some negatives to electronic charting. As stated above, down time for upgrades is always an annoyance. It causes inconsistencies in the patent record and is a hurdle for newer staff that never used our paper flowsheets. Some aspects are actually more time consuming than that of paper charting. Lags in servers and computer glitches often time cause sluggish operating systems. And of course there are always times when you have almost finished charting a long, detailed note, when the whole system crashes!

Grievances aside, I guess at the end of the day we all know that patient safety is the most important concern. With that said, I must admit that electronic charting is much safer than that of paper, therefore it wins my vote. As stated earlier, there is little room for misinterpretation. There is consistency among all staff, and patient records can be accessed by physicians anywhere in the hospital. Perhaps we are in the initial stages of developing a universal system that can be accessed by all institutions across the country. Wouldn’t that be nice!

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Posted in Electronic Medical Record | 9 Comments »

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