Archive for the ‘Standardization’ Category

Identifying National and International Standards to Benefit the Health Care Consumer

July 8, 2013

Standards help to define processes and methods. In the health care environment, the development and acceptance of standards to be implemented within the United States is slow. Lack of standards has slowed the development of an integrated delivery system within the United States, not to mention international standards. This is unfortunate in how it can affect the health care consumer. Many health care consumers have health care issues and experiences, whether it is for themselves, family, or friends, in different health care facilities nationally and internationally. If there are people, there will be illness and therefore health care is needed all over the world. Established standards, whether for electronic documentation processes or manual paper processes, would ultimately benefit the health care consumer by patient involvement and outcomes. It is commendable that there are standards development groups working at establishing health care standards to adopt nationally, as well as, internationally. The future development of electronic health records and other technological devices will continue to drive the need for standards and help prepare for future initiatives. The health care consumer of today is more knowledgeable of their personal health issues and also more responsible in their own care and outcomes. This is due in part by the requirement of hospitals and providers requiring the documentation of the patient’s current medication list. This is placing a responsibility on the health care consumer to become more aware and involved in their personal care of themselves or relatives. Along with the accessibility to health care information on the Internet, patient education departments, and other resources of health information, the health care consumer is becoming educated more than ever before. Health care standards organizations will continue the great tasks of establishing standards and perhaps there may one day be a set of specific standards identified within health care across the globe. With the vast developments of new technology, it will be interesting to be a part of what developments are accepted, adopted, and implemented as it relates to ones personal health care information.

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Why Standards?

May 1, 2013

We encounter standards everyday in our lives. From traffic lights, traffic signs, telephone key pads, keyboards, postal envelopes and paper sizes to the many areas of construction such as sizes of appliances, tools, wood, windows, and the list could go on. So, why are standards established? The term standard is defined as an established norm or requirement; it establishes uniform or technical criteria, methods, processes, and practices. Standards enhance the capability to improve production and decrease costs associated with creating the end product. By establishing standards this enables companies to increase workflows and efficiencies. When a customer or end user learns the rules or knows the standards, this allows them to become proficient and knowledgeable in the use of the tool or issue at hand. For instance, when a person drives to another state, the traffic signs and signals are the same or standardized across the nation. One does not need to re-learn traffic signs for every different place they drive. Established standards that are implemented and followed in health care environments increases the quality of care, workflow processes, saves the organization money, and ultimately improving patient safety and patient outcomes. Benefits and improvements affecting the delivery of care will be evident when standards are adopted internally by health care organizations, whether developed for the betterment of the organization or by regulatory agencies. Process improvements will be identified with the implementation of standards. Obtaining high quality data and information and maintaining the integrity of the data comes from using recognized standards. As the implementation of the electronic health record is an initiative and included in strategic plans in many health care organizations today, standards are necessary. Defining standards will assist in improving the extremely complex arena of health care data, information, and information management.

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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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Standardized Language in Healthcare

November 18, 2011

As the electronic health record (EHR) becomes increasingly utilized across the nation, a standardized language will need to be implemented and followed. This will improve more accurate billing, informed patient management, increased precision of documentation, and improve knowledge. Functioning without standards would be chaotic, out of control, and confusing to all individuals. Standardization proves to enhance any process. With the strategic organizational initiatives of many physician offices, clinics, medical centers, and hospitals to implement an automated electronic environment for documenting a patient’s health history, which then automate other processes, the need increases for the uniformity of a language. The downside of the uncontrolled terminology of medicine has been accentuated by the computer age, because without standard vocabulary the ability to acquire knowledge about healing professions through information technology is limited. Many clinical applications available today have restricted utility because they cannot understand each other. It seems with the urgency of healthcare facilities implementing EMRs, the development of a standard language is critical and needs to be on a fast track to develop solutions. Healthcare information system developers are not waiting for the standards bodies, in existence today, to make these determinations. These developers know that precise medical words are needed to analyze the information from automated medical records, which will improve quality and service in healthcare. Rather than use any existing clinical vocabulary standard, they are creating their own dictionaries or vocabulary sets. Although this represents a slight improvement over un-encoded or free text documentation, each vendor working in isolation, are creating a terminology which cannot be read or understood by other systems. This makes the potential of data exchange and comparing impossible. It is imperative that healthcare organizations, vendors, and government agencies work collaboratively to implement measures to effectively localize, update, and disseminate healthcare terminologies, mappings, and other terminology-related content currently issued by national and international standards bodies. A standardized language in healthcare is something of a monumental task, but one that needs dedicated professionals in establishing these standards. Although some standard languages exist, developed by various standards organizations, the need is paramount of unifying a standardized language. Controlled medical terminology is essential to maximize the true benefits of implementing a fully operational EMR. Additionally, if all physicians, nurses, patients, hospitals, clinics, payers, and government agencies would commit to the same healthcare language, the one who unquestionably benefits from this is the patient who can be any one of us.

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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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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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The Need for Standardization. Is it necessary?

October 19, 2009

I have had the opportunity to listen to Steve Shaha twice now in my career. He is able to place standards of care in a completely different perspective. He uses charts and slides and math and statistics. He makes his information usable and understandable. He assists hospitals with the information that he gleans from charts and is able to make correlations. He was able to work with a NICU out west and decrease there infant mortality by 75% in one year after discovering through patient chart reviews and collection of data that there was a cycle associated with the mortality rate at this institution. The cycle, he found, happened to correlate with feeding, and his discovery led to a change in how lipids were administered. This small change in care brought about the 75% decrease in mortality. Steve is also able to put his numbers into useful categories for us non-math people. The change that was instituted at this facility saved the lives of 21 premature infants in one year. Numbers of a different kind for me. His work has brought care standards to the forefront to people who will listen. Hopefully the right people are listening.

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Indicators, comment

September 14, 2009

I just finished reading a post on Monitoring of indicators, our facility received accreditation on the first round as well and I was shocked! The amount of work and prep that lead up to the survey was overwhelming and added to our already great time constraints. Not only were we trying to run our departments but now the added stress of putting together information and evidence  binders was astronomical. However I learned so much from the process and how valuable indicators were for improved patient outcomes I have added, modified or implemented new programs and made changes to the way I run my department. I even won a recognition award for Quality Insurance this past year.

Original Post
September 2, 2009
Title: Monitoring indicators
My current place of employment gained full accreditation in 2007; it was our first attempt. I understand it is rare to get full accreditation the first time. I did not realize how important the monitoring of health indicators and tracking progress was at that time. We (the staff) only saw it as time consuming; and is it really necessary to the outcomes of our patients? Tracking of data allows us to monitor our progress of goal achievement and the ability to improve programs to meet the needs of our patients. As a result we have added new programs based on the needs and requests of our patients. It has also enabled us to acquire more funding to increase staff. I guess what I am really trying to say, healthcare tracking, indicators and data collection provide much needed information to improve services, allocation of funds etc… It’s interesting how my views of unnecessary and time consuming work have changed.

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Monitoring indicators

September 2, 2009

My current place of employment gained full accreditation in 2007; it was our first attempt. I understand it is rare to get full accreditation the first time. I did not realize how important the monitoring of health indicators and tracking progress was at that time. We (the staff) only saw it as time consuming; and is it really necessary to the outcomes of our patients? Tracking of data allows us to monitor our progress of goal achievement and the ability to improve programs to meet the needs of our patients. As a result we have added new programs based on the needs and requests of our patients. It has also enabled us to acquire more funding to increase staff. I guess what I am really trying to say, healthcare tracking, indicators and data collection provide much needed information to improve services, allocation of funds etc… It’s interesting how my views of unnecessary and time consuming work have changed.

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National electronic health record

June 26, 2009

In 2004, President George W. Bush charged the medical community to develop a National electronic health record.

“By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care.”

The purpose of the EHR is to share pertinent patient information among healthcare providers and healthcare institutions. Sharing the information will save the patient money, increase patient safety, and improve the quality of care. The difficulty with this initiative is the variety of applications utilized to create and store the data.

As the need and ability to collect data has increased, so has the need to share the information, thus the development of technical health care standards. However, the lack of healthcare informatics standards to ensure the smooth transfer of data between systems is a major barrier to the national EHR initiative.

Another complicated area to deal with is the protection of patient information. Policies and Procedures are usually written at Healthcare Institutions that address patient confidentiality, electronic data access, integrity of electronic documentation, etc. Screen savers, privacy screens and short logout times are tools utilized on computers that are viewable by casual observers. Limiting access to the system based on job function is also used to secure patient data. The Health Insurance Portability and Accountability Act of 1996 mandates standards for developing unique patient identifiers that will provide privacy, security, and immaculate data transfer in order to link patient records.

The smooth joining of all this data is difficult to achieve. Institutions are currently challenged with trying to interface the different applications utilized in one hospital. It gets even more difficult when interfacing an entire Health System, let alone an entire nation of applications, patient identifiers unique, provider identifiers, etc.

In addition to the national EHR, hospitals continue to launch new applications to be used to support the care delivery. Over the years I have noted a lack of understanding regarding electronic signature, electronic documentation, access to patient records, etc. by nursing staff at all levels. The increase in electronic records has made information much more accessible to staff members but can also be deemed as too accessible if the staff members are not oriented to the confidentiality issues as they relate to electronic medical record access.

There is limited to no assessment of staff and their informatics knowledge on hire to healthcare organizations. Currently, the American Nurses Informatics Association is supporting a national initiative, Technology Informatics Guiding Education Reform (TIGER) aimed with writing competencies for nurses and nursing students to support the use of technology seamlessly in the delivery of safe and effective patient care. These competencies will incorporate theories, tools, and fundamentals of nursing informatics.

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