Topic 12: Health Care Information Systems and Management I
1. Describe documentation systems in various settings.
• EHR –has been used as a generic term for all electronic health care records in document systems that a
...
Topic 12: Health Care Information Systems and Management I
1. Describe documentation systems in various settings.
• EHR –has been used as a generic term for all electronic health care records in document systems that are portable (can follow client to other providers, specialists, other hospitals, nursing homes, etc.
• EMR – legal record created in hospitals and ambulatory environments that is the source of data for the HER at that facility
• HIT – Health information technology provides improved communication flow that is fast, timely, and available to all stakeholders (docs, nurses, client/family, pharmacy, etc.)
• CPOE – Computerized provider order entry = systems put into place for safety
• CDSS – clinical decision support provided via data collected on client to help team with clinical decisions
• Centers for Medicare and Medicaid Services (CMS) have set up Health Information Technology standards in US
• PHR – Patient healthcare record: information that can be managed by the client
o Clients can create their own records from collection of visit information from a
variety of providers
o Clients can access their own records from healthcare provider web based encrypted sites to view and print
o The systems set up from providers contain personal healthcare records that are private just for consumers and not shared; however, client can take that information and share it with another provider
o In some cases, clients can add to their providers information for the EHR kept by that provider (i.e. scan in labs or other healthcare information from another provider for primary provider records)
2. Identify standard components of the electronic medical record (EMR).
• Attributes identified by the Institute of Medicine (IOM) provide the basis for today’s understanding of the EHR
o Secure, reliable access where and when needed
o Records and manages episodic & longitudinal information
o Primary information source during care
o Assists with planning and delivery of evidence-based care
• Captures data for:
o Quality improvement, utilization review, risk management, resource planning,
performance management
• EHR components
o Information needed for medical record and reimbursement purposes
o Longitudinal, masked information supports clinical research, public health reporting, and population health initiatives
o Supports clinical trials and evidence-based research
o Client safety & security of private health information
o Restructures healthcare delivery system to improve the quality of care
o Cost containment
3. Explain the role of the EMR as a legal document, including nursing responsibilities.
• Healthcare records are legal documents
• Criminal investigations
• Financial impact
• Keep it confidential – Privacy laws
o Residence information
o Ethnicity/Sex/Birthdate
o Possibly whole or part of SSN
o Diagnosis
• Cyber-crimes are on the rise
• Data contains personal client information
• Protect from unauthorized users
• Maintain secure password management
• Automatized sign on (scanners)
• Grant access only on need to know basis
• Maintain professionalism
• Misuse & Consequences
o Negative comments may constitute hostile environment
o Civil and criminal penalties
o Fines/jail time
o Personal liability
o Termination of employment
o Poor publicity for hospital
o Board of Nursing will investigate mismanagement of client records, unethical conduct, and breaches in confidentiality
4. Determine how nurses integrate data management into daily nursing practice.
• Nursing role in healthcare with HIT
o Lead and assist in IT development
o Timely, accessible documentation
o Reduce medication errors
o Collaborate with physicians/other team members
o Assist in policy development
o Data mining/research for best practices
• EHR documentation
o Why do I document?
o Show client response to care
o Compile date from many clients to identify “best practice”
o Give evidence for reimbursement
o Provide proof of quality care
o Make a permanent record of care given
• In nursing, system for medication dispensation are used, such as the Pyxis, which holds most of the medications available to the nurse on the client care unit. Each medication is held in a different pocket of a drawer which the pharmacy fills. The machine can be extended with more sections to provide more drawer space, and refrigerated sections, if needed. When nurses need a medication for a client, they will sign in to the machine
and choose the correct client and the correct medication. The machine will determine if the medication is ordered, and if it is within the appropriate timeframe for the medication. It will then open the correct drawer for medication removal.
• Medications can be returned for credit to the client using the system process if they are not given. The medications are refilled by pharmacy on a routine schedule. Medications
not in the machine can be requested directly from pharmacy. Medications that a client is taking for more than one or two doses will be stocked in the machine for the nurse to pull. There is usually one machine for each nursing unit, with larger units having two or three. Note, some meds require two nurses to enter their ID for dispensation of particular meds.
• Some ICU’s/ED’s and units have bedside monitoring devices
o Bedside vital signs monitor connect direct to the EMR
o Nurse takes vitals which are imported directly into the chart
o VS flowsheets can be reviewed for comparisons of one or more selected vitals made into chart (visualized as list or graph)
• Glucometers may come with a docking station
o Serves as a charger
o Serves as a connection to the EMR logging in BS readings
o Chart/graphs can be viewed/reports generated
• Medication errors: The most frequent cause of adverse medication events which are preventable
• Technology which improves medication safety
o Computerized physician order entry (CPOE)
o Barcode medication administration (BCMA)
o Electronic medication administration record (eMAR)
• Laws from FDA require drug manufacturers to label all meds with barcodes since 2004
o Has increased incentives for facilities to utilize technology
• Each medication that is used bears a bar-code
o Applied by pharmacy
o Is coupled to a medication in the EMR ordering system
• Nurse medication administration
o Medication is scanned by a hand-held device that either is connected by wire to
the computer or is Wi-Fi transmitted.
o Nurse scans the client ID on arm band
o The computer will verify that the right medication was given to the right client at the right time, via the right route, at the right dose, right documentation
• BCMA serves as a secondary check -- nurse is responsible to check the 6 rights!
• The HIPAA Privacy Rule gives individuals who are the subject of a medical record (held by a covered entity such as a healthcare provider)the right to access their record, amend the record, obtain a copy, and direct that the record be provided to other healthcare providers. However, while the HIPAA Privacy Rule protects the privacy of individually identifiable information, individuals do not “own” the record and cannot take it from the
provider or have it destroyed. The same principles apply to information contained in a provider’s electronic medical record (EMR).
[Show More]
