Functions of Electronic Health Records

Functions of Electronic Health Records
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Task 1
* List four electronic health record (EHR) functions needed by clinical end-users in the acute care setting.
These include computerized provider order entry (CPOE), clinical decision support (CDS), point of care (POC) documentation, and electronic medication administration record (EMAR) (Amatayakul, 2017).
1 Describe how each EHR function listed in part A may be used.
The CDS is accountable for creating a problem-focused subjective, objective, assessment, and plan (SOAP) note templates and setting reminders for orders. Moreover, it evaluates the orders to ensure that they are error-free (Amatayakul, 2017).
The CPOE systems are used directly by the health providers who are licensed to enter orders. It tracks the orders and ensures their legibility to prevent errors in the prescribed and provided drugs. These can also countercheck the health insurance coverage regarding the patients’ treatment regimen (Amatayakul, 2017, p. 21).
The EMAR is essential in the fast delivery of care and medications, for it makes the records accessible even at the bedside. It is used to check for the drugs’ timing, frequency, and adverse effects on the patient (Amatayakul, 2017).
Lastly, the POC documentation is used to enter structured and unstructured data. The former refers to a preformed checklist that can be used for CDS analysis, while the latter is used to expound on the clinical case (Amatayakul, 2017).
2 Discuss one strategy that might be used when introducing new technology to integrate old technology in the acute care setting.
It is challenging to introduce new healthcare settings because there are already traditional ways to work. Nevertheless, its integration is essential to safeguard a better organization of patient and hospital data. Disorganized data can lead to medical errors that place the patients’ welfare at stake. One of the strategies that can be done is to incorporate a centralized repository to permit a smooth and progressive transition from the traditional written papers and old technologies to new technologies. Moreover, this allows the staff to simultaneously access old and new information, making them more comfortable adapting to the system. This will prevent the staff from being overwhelmed, increasing the chances of change acceptance (Amatayakul, 2017).
* List three EHR functions needed by clinical end-users in the outpatient setting.
1 Explain how each EHR function listed in part B is used.
First, clinical end-users in the outpatient setting treat individuals who need either acute, long-term management, or both. The CDS system component of the EHR can be used in these cases to create reminders for reimbursements like the laboratory and diagnostic tests. This is vital in ensuring that the procedures with time limitations are complemented by the payment reimbursements (Amatayakul, 2017).
Next, the CPOE system is a significant part of ambulatory settings because it aids the health providers in giving legible orders counterchecked by the system with the additional benefits of ordering laboratory and diagnostic examinations for the outpatients. Moreover, it provides pharmacy designations and assistance for the pending procedures. The latter is done by setting reminders related to the procedure, such as the materials, equipment, and medications needed for the support staff (Amatayakul, 2017).
The third principal function that could help the outpatient setting is the patient portals accompanied by the clinical messaging system, allowing access to patient information even outside the facility. It is also helpful for the other healthcare provider not duly assigned to the patient’s case when endorsed to them because they will view all the information related to the patient and his disease. This function allows for a comprehensive review of the patient’s case, making communication between staff and hospitals easier. Also, the portal can be used for e-visits in cases where the patient cannot personally go to the physician’s office (Amatayakul, 2017).
* Compare two models being used today in health information exchanges.
The federated model is the latest design that has consistent and inconsistent structures. The former relates to the central management of data only. Here, the data are physically separated from the structure, which is its difference from the consolidated model. On the other hand, the latter refers to the total division or classification of the data where each entity is placed within its system, and associations between these are established via shared points (Amatayakul, 2017).
Conversely, the consolidated model contains essential patient information that alerted a possible issue with patient confidentiality. It utilizes a system where individual institutions gain direct access to the data repositories. It has centralized storage, which is an excellent source of comprehensive data. However, it leads to the competition when multiple institutions access the system simultaneously (Amatayakul, 2017).
1 Describe benefits to developing health information exchanges.
The advantages of the use of Health Information Exchanges (HIE) systems include the following: 1) Better patient safety margins due to the reduction of medical errors; 2) Minimization or total eradication of disordered paper works and information handling, resulting in improved efficiency; 3) Increase in the number of successful treatments, which may be attributed to the CDS system; 4) Removal of unnecessary laboratory and diagnostic examinations; 5) Enhanced manner of reporting of patient progress; 6) Patient engagement; 7) High-quality care and improved patient outcomes; 8) Reduced health expenses (Health IT, 2019).
2 Describe current challenges preventing more widespread implementation of health information exchanges.
Generally, the challenges are related to inadequate funding, lack of technological infrastructures, outdated software, and insufficient staff training. Converting the hospital records requires a large budget because of the subscriptions to software and the changes or additions in the equipment. The newly bought equipment also needs maintenance or protection from potential hazards, which can also be attributed to the low funding. Next, the software is usually updating at least once annually. Outdated software may lead to errors in the system or, worse, loss of data. Lastly, the expertise of the users is significant to ensure the quality of data entered and accessed. This needs training, which the institution must also fund (Yaya et al., 2015, p. 4).
* Explain three factors an organization should consider when providing a personal health record to patients.
Generally, the three factors that must be considered in providing the patients their health records (PHRs) are the platform, data source, and integration. First, the platform is the medium to disseminate the information to a specific address. The type must be thoroughly assessed to ensure that it is appropriate for the population. Second, the data source entails its storage and accessibility. It is a vital factor that connects the platform and integration. The ownership of the patient record can be validated here, warranting the accuracy and reliability of the data. Moreover, this is where the information is validated before its dissemination to reduce errors. Lastly, integration is the comprehensive assimilation of various standpoints that aim to incorporate the inputs from several agencies, such as regulations of governing bodies and the institution’s policies (Amatayakul, 2017).
1 Discuss three qualities of a personal health record that should be determined before its adoption.
The three qualities that must be deliberated include functionality, security, and content. Sufficient functionality is necessary for excellent decision-making support, retrieval of data, and health education. The PHR needs to be easily navigated by the patients and health providers, and it must only provide the relevant information. Next, the security of the PHR is essential, but the patient might underestimate its significance. This entails privacy and confidentiality, and any leakage of information may harm them. Moreover, the mistake might be pointed to the health provider. Therefore, the patients must be educated on how to maintain the PHR properly. Lastly, the content of the PHR must be accurate, and this can be ensured through proper formatting, which guides the input of data. The levels of the information shown to the end-users, depending on their position, must also be considered (Amatayakul, 2017).
References
Amatayakul, M. (2017). Health IT and EHRs: Principles and Practice (6th ed). AHIMA Press.
Health IT. (2019, January 8). What are the Benefits of Health Information Exchange?. /faq/what-are-benefits-health-information-exchange
Yaya, J. A., Asunmo, A. A., Abolarinwa, S. T., & Onyenekwe, N. L. (2015). Challenges of record management in two health institutions in Lagos State, Nigeria. International Journal of Research, 1.
Task 2
A. Perform a needs assessment for the healthcare organization in the scenario by doing the following:
1. Describe one area needing assessment in the organization’s health information management (HIM) workflow.
HHS.gov (2020) states that patients have the right to access protected health information (PHI), either entirely or partly, within thirty days upon sending the institution their request. Due to the location of the charts, the ROI officer cannot promptly apply the deficiencies and incurs errors on the release of information. The issue is the lack of accessibility that increases the chances of delay and errors secondary to counterchecking the documents.
2 Explain one concern related to adopting an EHR that staff from the area needing assessment in part A1 may have.
Most of the staff, including nurses and physicians, are concerned about the difficulty of using new technologies, and they are apprehensive because of the familiarity provided by the written charts. They worry that its serviceability and lack of training in using an EHR may affect the workflow more than the delays caused by the traditional charting methods. Ajami & Arab-Chadegani (2013) suggested that opposition to EHR use will eventually lead to its failure, even when it has been approved.
3 Explain the functional needs that staff members in the HIM department may have.
Their functional needs are centered on usability and other factors, including simple and reliable access to health information records, stem from it (Amatayakul, 2018). The distance or the lack of knowledge of the location of the patient record (i.e., in another department) impedes the staff’s rapid retrieval of information, which may disrupt the workflow. This will also pose difficulty when it comes to emergency cases that need prompt treatment. Without the patient records, medical errors might ensue. Moreover, tracking down the charts may have privacy and ...