Nursing Informatics: Implementation of an EHR System Presentation

Introduction

There has been an growing curiosity in EHRs within the healthcare sector as sufferers demand for safer and better high quality well being and medical care.

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This curiosity in EHR has gone hand in hand with an increase within the variety of efforts made in direction of offering definitions of the time period.

Various names have been used to explain EHRs which embrace: digital medical report, digital affected person report, computer-stored affected person report, ambulatory medical report, and computer-based medical report.

The purpose of this presentation is to introduce a brand new EHR system to members of workers of a healthcare unit.

Importance of Information Access

Timely and correct entry of affected person data is necessary in enhancing the standard of affected person care.

Paper information have at all times been used as the primary strategy of organizing all accessible data associated to the progress of sufferers in addition to their prognosis and therapy at a specific place (Hamilton, 2010).

This compressed storage system is expedient however is rife with quite a few demerits which have been addressed by the digital system.

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Even if paper information might be duplicated, sustaining many copies of a single report is cumbersome as a consequence of restricted space for storing and the necessity to preserve updating all well being information.

The single-record system availed by the digital well being report system allows a number of suppliers to achieve entry to the information.

The system additionally makes it potential for suppliers who’re geographically constrained to entry the information.

The digital well being information are often saved in several places of the pc reminiscent of the primary location, the onerous drive and exterior storage amenities reminiscent of flash disks. It is thus simple to exchange an digital well being report if the pc system crashes (Hamilton, 2010).

The digital well being information are often saved in several places of the pc reminiscent of the primary location, the onerous drive and exterior storage amenities reminiscent of flash disks. It is thus simple to exchange an digital well being report if the pc system crashes (Hamilton, 2010).

Personal Health Information

Personal Health Information (PHI) refers to any data that’s collected by healthcare suppliers to determine their shoppers (College of Nurses of Ontario, 2009).

PHI consists of data such because the medical historical past of the consumer (and his household), bodily, psychological and psychological standing, historical past of medical/well being care obtained, amongst others.

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PHI is extra weak to breaches of confidentiality for varied causes.

PHI is in some circumstances required by an insurance coverage firm of the consumer to facilitate protection of the healthcare expenditures. In such conditions, breaches in confidentiality can simply happen.

When a consumer is incapable of constructing his personal choices in regards to the healthcare required (for example comatose sufferers), the nurse could also be pressured to share his PHI with members of his household to who could make the choices on the consumer’s behalf.

PHI allows employers to know in regards to the well being standing of potential and precise staff, for example, if the consumer smokes or has a terminal sickness that will have an effect on his productiveness. A breach of confidentiality can happen if the employer requests for the non-public data of the consumer with out the information and consent of the consumer (College of Nurses of Ontario, 2009).

Security Measures in Relation to HIPAA

The Health Insurance Portability and Accountability Act was enacted in 1996 by the United States Congress to reinforce the privateness of sufferers’ data (Sullivan, 2004).

HIPPA necessities embrace:

  • Providing sufferers with the documentation of their rights.
  • Protection controls on information saved wither bodily or in laptop methods.
  • Monitoring gadgets to trace the actions of the group’s data community.
  • Carrying out danger analysis, prevention of knowledge loss, and instituting information dealing with insurance policies.

In order to adjust to HIPAA, varied safety measures might be taken together with:

  • Delegating the responsibility of HIPAA compliance to a person or a group of people who will oversee all the compliance technique of the group (Sullivan, 2004).
  • Training of staff to create consciousness about HIPAA: staff needs to be skilled on the principles and rules of HIPAA, making certain the privateness and confidentiality of affected person data, find out how to shield affected person data, and who’s allowed to entry affected person data (Sullivan, 2004).
  • Restricting and monitoring entry to affected person data: entry to PHI needs to be restricted to solely those that require it reminiscent of healthcare suppliers. Monitoring needs to be carried out to determine who used the PHI, at what time and the way ceaselessly. This might be achieved utilizing identification and entry administration (IAM) instruments (Sullivan, 2004).
  • Use of knowledge safety methods reminiscent of firewalls and passwords to reinforce the privateness and confidentiality of the PHI (Sullivan, 2004).
  • Even although rigorous safety measures needs to be put in place to guard the privateness of well being data, additionally it is in the most effective curiosity of the affected person for the EHR to be accessible to the approved personnel for correct and lawful utilization (Sullivan, 2004).

Quality Improvement and Errors Reduction

An digital well being report can reduce the time taken to report data in addition to the errors incurred within the technique of documentation, thus enhancing the effectivity of healthcare staff.

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In addition, whereas paper information improve the chance of medical errors as a consequence of illegible notes, digital information reduce such errors as a result of the information are in a fashion that’s legible.

The elimination or minimization of medical errors is among the main considerations of shoppers in terms of receipt of well being and medical care.

Patient security is very advocated for and the implementation of digital well being information is a step in the suitable route in direction of the achievement of affected person security (Hamilton, 2010).

Roles of Implementation Teams

The success of an EHR in a hospital largely is dependent upon the implementation group. Taking into consideration the massive measurement of the hospital, the implementation group will include representatives of: physicians, nurses, operations workers, monetary auditor, tremendous person, well being data administration workers and data methods workers. These people will make up the planning group.

The position of the planning group is to make it possible for all parts of the EHR, together with the safety of the system and sources and availability of funds, are considered in planning, selecting, implementing, coaching and later use (Amatayakul & Lazarus, 2005).

Besides the planning group, the implementation group may even include consultants and authorized counsel.

The advisor will act because the mission supervisor who will assist in clarifying the goals of the HER, identification of acceptable suppliers, negotiation of contract, and implementation of the EHR system (Amatayakul & Lazarus, 2005).

Sustainability of the EHR needs to be ensured by involving all of the members of the planning group in every stage.

The authorized counsel’s position is to guage the phrases and circumstances of contracts and the compliance of the EHR with guidelines and rules reminiscent of HIPAA (Amatayakul & Lazarus, 2005).

Discussion Guide

Do you assume machine expertise and caring can exist individually?

Yes. A nurse could also be competent in using machines however not caring to the sufferers.

How is the harmonious relationship between machine expertise and caring illustrated by nurses?

Nurses can use the machine applied sciences to have a greater understanding of their sufferers in order to supply them with higher and high-quality care.

What are a few of the methods wherein nurses can present their technological competence and nursing on the identical time?

By grounding their observe on the framework of caring quite than on technological competence.

Need for frequent updating of affected person data.

How potential is it to compromise caring of sufferers via equipment?

The chance is excessive and due to this fact it is necessary for nurses to appreciate that machine expertise ought to solely be utilized by the nurses to know their sufferers as a complete and due to this fact using expertise mustn’t substitute nurses’ caring.

How are applied sciences helpful to nurses so far as caring is worried?

When nurses are technological competent, they can discover new and enhanced methods of constructing sturdy and therapeutic relationships with their sufferers.

Name three traits of expertise that differ from human beings and which affect caring by nurses.

Machines and applied sciences are invulnerable, goal, and predictable whereas human beings are weak, subjective and unpredictable. Professional nurses are challenged to be technologically competent and on the identical time to acknowledge human vulnerability in responding authentically and deliberately to calls of nursing.

When a machine/expertise is used on a affected person , how is the humaneness of caring achieved?

Even with using expertise, nurses ought to at all times bear in mind the human face behind the expertise. They mustn’t ignore the necessity of the sufferers for human interactions. Nurses ought to thus act as liaisons between the machines and the sufferers.

What are the necessities for the coexistence of expertise and caring?

Successfully combining expertise and caring requires sensitivity to sufferers’ bodily, emotional and non secular wants.

What is the dilemma of expertise proficiency with out the caring perspective?

The nurses fail to acknowledge their sufferers as human beings who’re complete and due to this fact the side of caring is non-existent.

One of the hotly debated points in nursing is “high-tech versus high-touch” debate. What are your opinions about this debate?

High expertise performs an necessary position particularly within the accuracy of knowledge collected, prognosis, therapy and remedy. However, an excessive amount of concentrate on the expertise is detrimental to sufferers’ care as a result of little consideration is given to sufferers. Therefore, nurses ought to combine and strike a steadiness between high-tech and high-touch points of nursing.

Reference List

Amatayakul, M. Ok., & Lazarus, S.S. (2005). Electronic well being information: reworking your medical observe. New York: Medical Group Management Association.

College of Nurses of Ontario. (2009). Confidentiality and Privacy – Personal Health Information. Toronto, ON: College of Nurses of Ontario.

Hamilton, B. (2010). Electronic Health Records. New York: McGraw-Hill.

Sullivan, J. (2004). HIPAA: A sensible information to the privateness and safety of well being information. Chicago, IL: American Bar Association.

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