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The Paperless Hospital : Electronic Health Record

The Paperless Hospital : Electronic Health Record. Brenda Graham, RN, CDN Penn State University NURS 457 – Summer 2009. Objectives. Define/Describe The Paperless Hospital – Electronic Health Record (EHR) Identify Hardware/Components used in EHR Identify Software used in EHR

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The Paperless Hospital : Electronic Health Record

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  1. The Paperless Hospital: Electronic Health Record Brenda Graham, RN, CDN Penn State University NURS 457 – Summer 2009

  2. Objectives • Define/Describe The Paperless Hospital – Electronic Health Record (EHR) • Identify Hardware/Components used in EHR • Identify Software used in EHR • Evaluate usability of Software • Describe/Review Information System

  3. Objectives – EHR • Review Advantages and Disadvantages • Review Ethical and/or Legal Issues • Review Informatics Competencies for EHR • Review Informatics Nursing Functions and Responsibilities • Summary

  4. Definitions • Paperless Hospital • Health care delivery model that is based solely on use of technology • Health care records, diagnostics tests, billing, education, etc. - all in digital format • The future of health care delivery systems (YouTube, 2009)

  5. Definitions continued • Electronic Health Record (EHR) • Multiple definitions available in the literature • Institute of Medicine is the most recognized • Multiple essential components include: • Health data and information • Order communication and diagnostic management • Reporting and community health management • Support services for health care professionals and patients • Connectivity • Education • Administrative processes such as billing and claims as well as patient scheduling (McGonigle & Mastrian, 2009)

  6. Hardware Components • Protective Outer Casing • Central Processing Unit • Motherboard • Power Supply • Input/Output Devices and Connection Ports • Hard Disk, Memory (RAM, ROM, Virtual) (McGonigle & Mastrian, 2009)

  7. Hardware: Options for EHR • Desktop PC (personal computer) • CPU (central processing unit – the brain) • Monitor • Keyboard • Mouse • Laptop PC • Tablet PC • Convertible • Slate • Handheld PDA (Personal Data Assistant) • Printer • Scanner (DOQ IT, 2009)

  8. Hardware: Handheld PDA (DOQIT, 2009)

  9. Software Requirements What application programs do I need to use the EHR? • Operating System – fundamental component • Productivity – most common • Communication – crucial for networking (McGonigle & Mastrian, 2009)

  10. Software: Packages for EHR • Allscripts Professional or Enterprise • Epic • HII – Health Informatics, Inc. and TIME (Total Information for Managing Effectively) • InteGreat • MediNotes - Microwize Technology (Allscripts, Epic, HII, InteGreat, Microwize, 2009)

  11. Software usability: Epic Care • Easy to learn • Easy to use • Efficient use of programs • Error prevention • Appropriate for specific task requirements (McGonigle & Mastrian, 2009)

  12. Information System: HII/TIME • Multiple Information Systems used for EHR • HII/TIME specific to chronic disease market • Dialysis realm strongest presence • Integrated Clinical and Financial Information System • Point of Service/Care Configuration • Used by nurses, physicians, unit assistants, financial clerks and officers • Able to perform registration tasks, clinical documentation and medication administration, billing and service charges (HII, 2009)

  13. Data Standards: HII/TIME • American Society for Testing and Material (ASTM) • HII is a member of ASTM • Provides communication protocols • Health Level 7 (HL7) • HII is a member of HL7 • Industry Standard in Health Care (HII, 2009)

  14. HII/TIME: Advantages • Easy to learn and easy to use • Helps enforce policies and procedures • Provides functional reports for quality improvement • Has alerts built into system • Captures more charges, increases revenue • Sends out claims faster • Faster physician order implementation • Enhances decision making • Real-time access and charting by exception (HII, 2009)

  15. EHR Advantages • Improved patient safety • Improved documentation quality: order entry and legibility • Date and time stamped • Increased revenue • Intelligent alerts and quality improvement capabilities • More efficient turn-around time for diagnostic results (McGonigle & Mastrian, Rehab management, 2009)

  16. EHR Disadvantages • Expensive • Multiple products to choose from • Technophobia and resistance to change • Technical issues: downtime, backup systems • Questionable: future accessibility and security • Interoperability and lack of integration and standardization (McGonigle & Mastrian, Rehab management, 2009)

  17. Ethical and/or Legal Issues • HIPAA: Privacy and Confidentiality • Legal Standards • Interoperability • Ownership (McGonigle & Mastrian, Rehab management, 2009)

  18. Informatics Competencies • Basic computer skills and understanding • Ability to document information electronically • Ability to access information electronically • Search databases • Use software for charting and medications • Ability to use e-mail helpful (McGonigle & Mastrian, 2009)

  19. Informatics Nursing • Change Management • Involve clinical staff from beginning of process • Assess attitudes and concerns • Involve clinical staff in all implementation stages • Make sure systems are user-friendly • Provide adequate training prior to implementation • Provide continued education and support (McGonigle & Mastrian, 2009)

  20. Summary • Primary focus of the Paperless Hospital is the EHR • New health care technology demands adaptation from professionals • Benefits outweigh the drawbacks of the EHR • Further advances will occur in the near future • EHR will be readily accessible • Laws will protect privacy and confidentiality

  21. References • Allscripts-Misys Healthcare Solutions, Inc. Electronic Medical Record EHR Solutions for Physicians Medical Records. Retrieved June 18, 2009, from http://www.allscripts.com/products/electronic-health-record/default.asp?src=GoogleAdd& • DOQ IT. EHR Hardware Solutions. Retrieved June 18, 2009, from http:/www.internetifmc.com/provider/documents/ehr_hardware_solutions.pdf • Epic Systems Corporation. Epic with the patient at the heart. Retrieved June 17, 2009, from http://www.epicsystems.com/software-ehealth.php • HII – Health Informatics, Inc. HII’s Clinical Software. Retrieved June 17, 2009, from http://www.hiiweb.com/clinical.html • InteGreat. EHR Software. Retrieved June 18, 2009, from http://www.igreat.com/EHR_software.html

  22. References continued • McGonigle, D., & Mastrian, K., (2009). Nursing Informatics and the Foundation of Knowledge (1st ed.). Jones & Bartlett Publishers, Sudbury, Massachusetts. • Microwize technology. EMR/EHR Medical Software. Retrieved June 18, 2009, from http://www.microwize.com/emr.htm • Rehab management. EHRs: Issues Preventing Widespread Adoption. Retrieved August 7, 2009, from http://www.rehabpub.com/issues/articles/2007-06_09.asp • YouTube. Paperless Hospital. Retrieved May 28, 2009, from http://www.youtube.com/watch?v=6ueTFjcTtco&feature=related • YouTube. Paperless Hospital. Retrieved June 7, 2009, from http://www.youtube.com/watch?v=9jAH9hdF0xk&feature=related

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