The Facilities are Characterized by Treatment Variations

The Facilities are Characterized by Treatment Variations
In the current age, healthcare facilities are seeking alternative ways the delivery quality and affordable care to patients. Despite this, the facilities are characterized by treatment variations, unsafe practices, and increased patient mortality rates across healthcare facilities. An emerging recommendation to address the challenges is the integration of information technologies to improve the quality of care and reduce the costs of healthcare services delivered. However, implementing information technologies requires a detailed plan with essential considerations for achieving primary targets and overall success. There are different requirements for successfully implementing health information technologies for quality improvement and cost reduction. Since most healthcare facilities are adopting clinical information systems, exploring the flow of clinical and non-clinical data in an inpatient electronic health system is necessary. The discussion begins from the provision of laboratory reports, through various data points, to the final stage of discharge after treatment, establishing a foundation for recovery.
Laboratory Report- Emergency Department
Laboratory reports are critical components in the patient’s disease management. The advancement of diagnostic procedures, equipment, and facilities facilitates diagnosis optimization and the development of efficient individual treatment plans (Harith et al., 2016). Further, the authors note an increase in the reliance on laboratory reports through the shift in the demand for critical service among physicians in different healthcare facilities. As healthcare facilities integrate information technology systems, including laboratory results is becoming commonplace. The automation of sharing information necessitates smooth sharing between providers and patients, optimizing the patients’ clinical outcomes. Most data available in the electronic systems across health facilities are generated from laboratory results. The information is available through the transmission from the on-site laboratory to the electronic systems in the facility (Kratz, 2016). Individuals with access to the reports can access other critical details, including the time and date of the collection and release of results.
The best laboratory data should be supported by health information systems employed by independent laboratories that are mostly, though not continually, included in the inpatient EMR system. More specifically, laboratory data for inpatient EMR systems include lab results and orders. Accordingly, the coding requirements for lab results and lab orders include the Current Procedural Terminology (CPT), the Systematized Nomenclature of Medicine (SNOMED), and the Logical Observation Identifiers Names and Codes (LOINC) (Gliklich et al., 2019). Today, there exists no compulsory lab coding system for inpatient EMRs, and many health care professionals depend on localized coding structures for lab results or orders. This constrains the multi-site EMR-derived lab information interoperability in the context of registries. Further, healthcare organizations might employ precise laboratory tests to assess a similar analyte, each incorporating a unique laboratory code (Gliklich et al., 2019).
There is a need for discussions across the healthcare provider networks regarding how to connect laboratory items, preferably by employing automated instruments rather than a traditional method, to guarantee that one query within the system would provide all the required information from diverse EMRs for the specified record. Moreover, state, and federal laws protect some laboratory results (e.g., those indicating the client's HIV test outcome) and, therefore, could be absent within the inpatient EMR excerpts reporting to records within the external environment. In addition, some clinicians are allowed to access specific laboratory data without it being incorporated into the inpatient EMR system. In this context, there are chances that inaccurate interpretations could be made without comprehending why specific laboratory data does not meet inclusion criteria in the inpatient EMR system. Detailed laboratory data prompts the clinician to take active steps in importing it into the inpatient EHR system (Gliklich et al., 2019).
Physician's Orders – ER or Direct Admission
An admitting physician manages the patient's health requirements during admission. The admitting physician collaborates with the (RN) to discuss or review the physician's orders. Notably, the physician's order documents can be completed electronically, in writing, or verbally according to the facility's requirements. However, electronic/computerized order entries are preferred for their benefits in patient care. Since the provision of patient care is prone to errors, computerized order entries can assist in managing such blunders. Jungreithmayr et al. (2021) indicated that implementing automated entries improves the quality of prescriptions. Automatic orders are also essential in improving efficiency through proper documentation and transmission, making the process faster and less time-consuming. Such a benefit ensures the provision of quality patient care after referral. Automated order entries in the admitting physician's electronic health system also help improve reimbursements since pre-approval is necessary for some order requests.
Patient Admission – Admission Department
If the patient's records are available in the system, the admission department team will proceed with the admission process. If the patient's details are lacking in the records; they must complete paperwork under the guidance of the Admitting Diagnosis (AD) and proper coding. After documenting the patient information in the electronic records, the admission department obtains insurance information for billing purposes. Afterward, the registered nurse (RN) executes the assigned responsibilities. Since the (RN) is one of the first points of contact between a patient and the facility after referral, they should obtain and document the patient's medical history in the electronic health records. Such records have several benefits, including reducing medication errors, facilitating treatment, and enhancing the contribution to external/internal registries (Schopf et al., 2019). It is also the responsibility of the (RN) to conduct a physical examination for abnormalities. The nurse also educates the patient on the recommended procedures, medications, and recovery process. The (RN) collaborates with the admitting physician to complete the physician order forms.
Physician Referral – Admission Department
Patient referral is an essential data point in an inpatient electronic system in case the previous facility had insufficient resources to address health concerns. Thus, it is critical to provide timely patient care recommendations in primary care. The referral process requires coordination between clinicians and patients for outcome improvement and optimization (An et al., 2018). In this context, the physician writes a consultation referral request to a specialist seeking help with a patient's diagnosis as well as treatment. The physician includes all necessary data concerning the client and the reason for referral. Before admitting the patient, it is necessary to consider whether the specialist is available or if the patient is in the health system. Since the physician's and the specialist's facilities are interconnected in a network through an electronic health system, exchanging patient information in a safe and convenient pathway is necessary. Such an exchange is the basis of information interoperability in healthcare facilities that prevents poor information sharing, which affects care quality.
Medical Equipment & Supplies – Primary Unit
Different medical equipment and supplies should be procured from the pharmacy to assist in the patient's diagnosis and treatment. Pharmacological supplies improve patient health through accurate diagnosis and treatment administration. Although most functions revolve within the pharmaceutical department, physicians and pharmacists should collaborate through information sharing for optimal treatment. Regardless, some potential barriers can hinder such collaborations. The obstacles include lack of information, heavy workloads, burnout, and time constraints. Physicians should inquire from the pharmacists about the availability of required equipment and supplies to assist in diagnosis. The respective departments should avail the supplies for efficient diagnosis and treatment. All surgical instruments should be available in the surgical room if a surgical procedure is necessary. The pharmacist should include these instruments in the patient's medical records for reimbursement. Failure to document the equipment and suppliers affects the reimbursement process challenging the payment of services rendered in a facility. Thus, documentation of proper medical equipment and supplies is necessary to smooth clinical and non-clinical data flow.
Radiology Reports – Radiology Department
Radiology reports can be conceptualized as procedure data. Research indicates that procedure data can be defined as data that includes clinical processes such as laboratory, pathology, radiology, and surgery. The inpatient healthcare worker can derive procedure data from the reported registries or the inpatient EMR system. However, procedures reported from the inpatient EMR system only incorporate those procedures conducted within the healthcare organization premises using a similar EMR system and might not include procedures that happened in other healthcare facilities. The International Classification of Diseases Clinical Modification (ICD-CM), Healthcare Common Procedure Coding System (HCPCS), and Current Procedural Terminology (CPT) are the vocabulary standards for the procedures mentioned above....