Chapter 7
Health Information Technology Functions
Lisa A. Cerrato, MS, RHIA and Jane Roberts, MS, RHIA
Real-World Case
This case study presents a healthcare facility’s journey toward implementation of an electronic health record. It demonstrates the complexity of the process and similarities that exist between paper-based, hybrid, and electronic health records.
Background
Central Community Medical Center (CCMC) is a 600-bed urban hospital located in the downtown of a major metropolitan area. The medical center is one of five hospitals belonging to the Midwest Healthcare systems. The medical center is a full-service teaching hospital with services ranging from medical, surgical, obstetrics, pediatrics, wound care, trauma care, and heart
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Once each form was identified, a barcode was applied to paper forms that would be scanned into the EDMS. The barcode on the forms was needed so forms could be automatically indexed and routed to the correct location within the EDMS. Indexing rules were applied to scanned images and electronically fed documentation. The rules allowed the documentation to be auto-indexed to the correct location within the EDMS. Another task in form redesign was to standardize the location of the barcode on paper forms to be scanned.
The information systems (IS) workgroup used the documentation matrix to assist with the identification of computer interfaces that needed to be in place in order for electronic transmission of the documentation to work properly.
Workflow Analysis
Workflow analysis was also performed on the paper-based HIM procedures to see what processes in the current workflow could be eliminated and what new processes would need to be implemented with the adoption of the electronic health record components. The current workflow was graphically demonstrated in a process flow chart. Several work processes that existed in the paper-based environment were replaced or
This case analysis of Stanford’s Hospital and Clinics (SHC) electronic medical record (EMR) system implementation will focus on how the healthcare organization focused on resolving a problem to meet regulatory pressures and responded to an opportunity to create operational efficiency, by capitalizing on the use of information technology to help reduce costs. We will discuss the organization’s IT problems, opportunities, and the alternatives available to address each. We will summarize an analysis of potential alternatives including the organization’s EMR system of choice and conclude with a recommendation to the Board on how to rollout the new system.
The procedures that need to be followed when retrieving information for paper based information consist of finding out whether you are allowed access to the information, finding out where the information is stored if you are allowed access to it, looking for the information, taking it from its storage place remembering how it was stored for when the information is to be put back. The procedures that need to be followed when deleting information for paper based information consist of finding out if the information is confidential or not normally something that is confidential has address or names on it, if the information is confidential then it needs to be cross-cut shredded if the information is not confidential then it can be shredded normally. The procedures that need to be followed when archiving information for electronic based information consist of checking to see if the information contains legal information or long-term business obligations, checking to see if there is more than one copy of the information, if there is more than one copy of the information check to see if the extra copies can be deleted, if the
As electronic health records are conceptualized in order to better fit the workflow patterns in physician offices, the insights from our electronic health record system in several cases identified affordances which were available in a paper-based system but were not easily translated into the current generation of electronic health records. Their comments are not provided in order to suggest a return to paper, but rather to identify functionality to support with the electronic health record design as well as with choices made during the implementation of electronic health records. There are several ways in which paper-based documentation was more flexible in nature. One is that access to a piece of paper for entering, viewing, highlighting, updating, and annotating information was done by other means (primarily physical constraints) than by an electronic login with an associated defined organizational role.
Patton-Fuller Community Hospital is a prominent hospital that is known for specializing in pharmacy, radiology, surgery, and physical therapy. This community hospital has numerous departments and each has a different IT need, so understanding which programs will work and be compatible is their major objective. The patients of Patton-Fuller Hospital are accustomed to the quality service
Our one hundred bed hospital is in need of updating from paper charting to computerized health records. In doing this, we will meet our goal of compliance with meaningful use legislation. We assembled a team of members to assist with this task and together we have narrowed the search to two health care systems. Those two systems are EPIC and Meditech and we will now discuss the advantages and disadvantages of each, with a final recommendation for our new healthcare system.
Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,
Despite some barriers and challenges of EHR adoption, transitioning our office to paperless has become inevitable. Timely adoption of EHR would help our clinic receive incentives, merge paper records into the new database, and better organize patient information. In order to ensure the most seamless implementation possible, meticulous planning will be a must.
Over the previous eight years, there has been a significant investment of private and public funds to upsurge the adoption of Electronic health records (EHRs) across the nation. The extensive adoption and “meaningful use” of electronic health records is a national priority. EHRs come in various forms and can be utilized in distinct organizations, as interoperating systems in allied health care units, on a regional level, or nationwide. The benefit of utilizing an EHR depends heavily on provider’s uptake on technology. Benefits related to electronic health records are numerous and may have clinical, organizational and societal outcomes. However, challenges in implementing electronic health records has attained some attention, the implementation
obligations in documents and alerts. Ease-of-use and functionality of workflow processes in the EHR system are key considerations for selecting the system vendor. Consequently, the needs assessment, readiness assessment, and the workflow analysis are fundamental steps to decide if an EHR system is convenient to be implemented in your healthcare facility, however the workflow analysis will guide you in choosing and purchasing the best system that fits your institution. Mapping the workflow for various tasks enables recognizing the features and functionalities that should be in the EHR system. These features are important to be presented for the vendor as scenarios, and it is recommended to ask the vendor to show you how a patient record is initiated and managed based on your previous presented scenarios. This allows you to compare between vendors and clarify the usage of the software for various workflows in your institution. Only scenario-based demonstrations elaborate if the system’s smooth usability matches your institution workflow or not. Finally, it is critical to test-drive the system by yourself
Most of the paper-based tasks are time-consuming nonetheless due to the implementation of EHR, these paper-based tasks are converted electronically and consequently, save time and increases the productivity of the staff. For example, using an EHR template to collect data. Template is a preformatted file that provides prompts to obtain specific, consistent information. It allows efficient data entry using structured input options such as drop-down menus and check boxes. In addition, it facilities easy access to data due to its consistent format, thus avoiding time-consuming searches. The best thing about templates is that it can be customized according to the needs of the practice. Before EHR, the information was noted down in a paper chart by handwriting. The handwritten notes would consume time to depict the information due to its illegibility. The use of templates in an electronic chart is much quicker than recording on paper; less time is consumed to document
Meaningful use is the adoption and use of certified health record tech, entry/capture of data (vitals, orders), movement of data (transitions of care), report data (to larger clinical systems) (SuccessEHS, 2012). Issues
Over the last two decades the government, industry, and academia have been incraesingly recognizing the importance of health information technology. Healthcare has tended to lag other industries (like communications and financial services) in transiting to electronic records. However, as proprietary electronic medical record (EMR) systems get deployed at healthcare organization, so does the need increase to exchange records via a Health Information
The process of migrating from paper-based charts to electronic records is a complicated process that requires dealing with all issues. The process has no particular route, but strategic planning and execution are necessary so that all risk issues get dealt before they happen. The article proposes changes made depending on the ambulatory care. The goals must become tactical, reasonable and measurable. The process requires a timeline that’s needed to ensure human resource and financial resources meet all the demands. An assessment of the hospital’s readiness determines the software and hardware gap, employee competencies and training, and human technology interaction.
This case study is based on the integration of electronic medical records known as EMR. The integration process came from Dryden, New York and was tested by a small medical practice named Dryden Family Medicine. The practice has been known for its outstanding family based services given to their community. The implementation process of EMRs doesn’t come without risks, but with its outstanding paper based medical record keeping that continued to expand as the practice grew left the Dryden Family practice no other choice but to try out something new in hopes for a better outcome.
Papers based systems work but are time consuming. The paperwork burden in hospitals is obvious. Unlike just about every other industry, health care still relies on an old-fashioned paper/fax/phone transaction process. These paper based systems