Improving Patient Care free essay sample

There is growing enthusiasm in the United States about the use of electronic medical records (EMRs) in outpatient settings. More than $20 billion of the federal economic stimulus (the American Recovery and Reinvestment Act of 2009) is slated to assist physicians, hospitals, and other health care settings in adopting health information technology (Gill, 2009). The government wants to shift into the digital era and it is highly recommended that all hospitals become compliant by 2015 and has provided reimbursement incentives and an electronic medical records deadline for those who adopt electronic medical records (EMR) however, as with all government benefits, this electronic medical records mandate comes with strings attached. For those who do not meet the electronic medical records deadline for implementation, the government has laid out a series of penalties (2009). The EMR system is in place to help improve patient care and (EHRs) can improve the ability to diagnose diseases and reduce—even prevent—medical errors, improving patient outcomes. The role a Health Information management (HIM) has in helping to Improving Patient Care and Quality Utilizing the Electronic Health Record is a very important and detailed job for the health care professional. The HIM professionals will be invaluable to ensuring the appropriate interpretation and conversion of healthcare data related to many uses, including patient data, organizational effectiveness and efficiency, policy making, and reimbursement systems. For example, the implementation of ICD-10-CM/PCS and other terminology systems such as SNOMED CT will necessitate a better understanding of how data are collected, analyzed, and reported to ensure information is understandable and useable (AHIMA Task Force on Healthcare Quality and Patient Safety). Many places offer services to help patients in ensuring they have access to their medical information so they are able to keep track of their care. BJC for example has offered the use of â€Å"My Health Folders†, where employees can manage all their family’s medical information in one Web-based resource. My Health Folders provides a portal for health information such as allergies, medications, immunizations, surgeries, test results and family medical histories. It also stores emergency contact information and a list of the user’s doctors, pharmacies and insurance information. This is something that not only aids in the patient in emergent situations it also helps in aiding the patient in keeping track of their medical information; they are able to trend anything that is unusual or concerning. This was once just offered to the employees and families of BJH but now through a community project they are now offering this to other individuals. BJC, which is the state’s largest nonprofit employer, now offers the program to other nonprofit employers for no charge. For-profit companies can participate for a flat fee of $5 per employee who signs up for the program. BJC also is offering the program to the 141 hospitals in Missouri for free. Secondary uses of health data to evaluate and improve healthcare outcomes and costs have received increasing emphasis. Quality measures are now an integral part of value-based purchasing initiatives at the federal, state, and local level. In addition; quality and patient safety measures include a variety of coded data variables as part of their definition (AHIMA Task Force on Healthcare Quality and Patient Safety). The use of EHRs from the perspective of the health care community is going to come with many ups and downs. There are going to be people in every atmosphere that are hesitant with any kind of change even if it is for the better. Any health care worker that works in a critical care area will have to admit that the use of an EHR is not only useful but it is safe, quick and has many resources that help in promoting patient safety. The EHR systems facilitate patient safety and quality improvement through: use of checklists, alerts, and predictive tools; embedded clinical guidelines that promote standardized, evidence-based practices; electronic prescribing and test-ordering that reduce errors and redundancy; and discrete data fields that foster use of performance dashboards and compliance reports (Carroll, Edwards Rodin). Although there are a lot of systems out there that say they are the best and even the best systems have their kinks in them but at the end of the day the only thing that matters is the patient and the quality of care they have received all with the use of the EHR. The EHR is a way for physicians across the board to understand their patients and not have to try and interpret different note from other health care professionals involved with the care of a particular patient. A successful EHR comes with a lot of hard work and not just from the top management it takes the work and input from the patients, employees who are using the system at the front end and then finally how everything computes down the line. However as previously mentioned with every system they are pitfalls. EHRs consist of both structured and unstructured data, leaving a variety of opportunities for error. With recent government initiatives, such as meaningful use, there is increasing pressure for healthcare entities and providers to attest to quality healthcare data. In addition, the data should be trusted to support clinical, financial, and administrative decisions. Current Joint Commission Standards are crystal clear on this point: The governing body is ultimately accountable for the safety and quality of care, treatment and services (Grennnen, 2013). There is always room for growth and as times change so does the health care system and the needs of the patients and to continue to give the patient the best care possible with the growing use of electronic medical charting there needs to be teamwork amongst all health care professionals. One of the biggest limitations of the electronic medical system is the fact that not all hospitals or health care facilities are on the same system. This is something that in future the government and health care professionals hope to change. There are so many different systems that each office uses that works for that particular office however, that does not mean that system is compatible with other facilities or even all parts of the same hospital. At BJH we use Compass in some areas, Clinivision, HMED, MEdScripts, ClinDesk, and many more that I am not ever familiar with. This is a problem in many different places because all systems do not talk to one another meaning they do not transfer data within themselves. This is something that can lead to patient safety because then we have to start sending faxes and scanning medical information that can end up in the wrong hands if not done properly which leads to a HIPPA violation. If the hospital uses a different EHR system than your primary care physician, health records may not be available to the hospital, or vice versa from hospital to the physician. A glimpse into the future of EMR systems consist of: Every provider, in every state, will have the ability to create an EHR for their clients or patients. Patients will have the ability to access their entire record with a provider online through patient portals. Providers will be able to share patient data electronically and seamlessly. Information exchanges will be established to assure continuity of care no matter where the patient is. Public health officials will have access to â€Å"real time† epidemiology information (Roberts, 2012). The development of EHR is still not over. The government has shelled out over $3 billion in incentives to help provides meet the requirements needed to become compliant with EHR. There have been a lot of changes in the health care field over the past decade alone and yet since 2005 the changes have been more patient orientated in the ways of quality and proficiency. Yes there have been medical breakthroughs but that is not the only thing we have that will provide a patient with the quality of their care. A system in place to keep track of their medical care and the way the way we in the medical field take notice to keep their medical information safe and up to code with data is also a huge part of the patient quality of care. The government set everything out in stages to help people adapt to the changes slowly but it was a long process and now that 2014 has come we see that there are many more challenges ahead. There are so many venders that are within the EHR system and only a percentage of them are ready for any changes to take place for stage two in the government’s plan. There are many of the challenges from the EHR in stage 1 that will be changing with stage 2 of the meaningful use tools in regards to the charting and chart sharing among doctors. The need for interoperability is critical. Patient data needs to be shared across enterprises. Meaningful Use Stage 2 sets some requirements for vendors to be able to export and import summary patient data (via creation / consumption / transport of C-CDA standard documents). There will be a way to streamline all the data in a smoother, quick setting so everything does not look and come at you looking clumped together and then there should be a way so that the systems will not lag. The implementation process is already set up so now from here on out we will only be building the EHR. The EHR is here to stay and the future will be that we will be able to hopefully be able to come up with a way to share the data will all systems in a safe fashion as to keep all patient data secure and at our finger tips. The EHR is being pushed more and more and should not even be second nature at this point in time. Everyone for the most part within the health care society should be using some sort of electronic charting system. However because not all people are computer savvy and are hesitant in change they are experiencing some difficulties still. Not only are the employees in the health care society experiencing challenged older people are not so welcoming in knowing all their personal data is on an electronic device. Most of these people do not understand that these changes are all for the benefit of them. There have been many studies among nurses and physicians to see how they have adapted to the use of EHRs and their devices. The studies conclude that both nurses and physicians see the added value of integrating EHR into their daily practice,17,59,62 physicians and nurses differ in their incentives to use the EHR56 and in their speed of adoption. 63 These can be influenced by the fact that nurses tend to work in a single location and will therefore be more frequently exposed to the EHR in contrast to physicians who tend to work in several locations, both inside and outside the hospital. The degree of exposure to a newly implemented EHR may influence the learning curve and ability to become an efficient user more rapidly (Poissant). We learned that expectations of EHR implementation projects that documentation time will be decreased are unlikely to be fulfilled, especially with physicians. However, EHR and CPOE systems can generate time savings in other activities, such as accessing a patient chart or maintaining patients report forms. Consequently, assessing the impact of EHR on an ensemble of work processes and outputs such as the effectiveness of communications across care providers as measured by patient outcomes (e. g. , reduction in medication errors, lower readmission rates) could potentially generate favorable results that would then act as incentives to physicians. This suggests that a shift from the users efficiency to the organizations or even the systems efficiency is needed. Such a shift will require that the EHR be seen as a tool that can transform work processes and support innovation in care delivery (Poissant). The resources in this paper that I choose I looked at very thoroughly and read the data to make sure it fit the needs of the information required for this paper. I was very careful to use reliable and resourceful data that could be useful in gaining more knowledge of the Electronic Charting System. If I could take something away from all this information that I did not already know little or part of I would say I did not know that in 2014 we would hopefully find a way to go to universal charting. With my career choice I am hoping to learn as much about the charting systems and the laws that surround them so that I can be part of a team to initialize a community EHR for the hospital I work for. I have learned there are so many resources to pull information from and some are so outdated that we have already surpassed the data that they have out there. I looked for data that can give us a hint of what it takes to put together a safe environment for storing and accessing all patient data. I am a patient somewhere and I hope that all my information is secure and that someone has my best interest in mind when sharing my data with another physician if that is the case. In summary, the EMR is a promising tool for improving quality of care in primary care and other health care settings. The EMR can facilitate disease management both during and outside of office visits. The EMR can facilitate a team approach to care and can help patients become a more active part of their team.. As with any tool, it must be used correctly to fulfill its potential. There are many pitfalls that can result in the EMR not being used to its full potential and therefore becoming just an expensive system for storing patient charts or a mechanism that adds regulatory burden but does little to improve quality (Gill, 2009).