Computerized Provider Order Entry With Decision Support, Patient Identification, And Test

1. The organizational behavior problems in this case are lack of leadership, lack of good communication and lack of resources. The hospital has poor leadership. The leaders have not put in place certain safe guards to deliver quality health care to their patients. First, patients are admitted on the spot without the consideration of other health care options. This also poses another issue of patient autonomy. Patients have the right to choose treatment options. Secondly, leadership has not ensured resources such as bilingual staff or other language interpreting services are in place for non-English speaking patients. This creates a communication barrier, which the hospital runs the risk of patients not fully understand information relayed to them. As a result, patients cannot make informed decisions. Understanding a consent form should not be the only documentation required to perform a medical procedure. The hospital leaders should use other forms such as published brochures to explain diagnosis, procedures, and patient rights and patient advocates before having patient sign consent forms.

The identified barriers are financial cost, physician and organizational resistance due to low computer literacy skills and disturbance of workflow caused by CPOE systems. The resistance can be overcomed by strategies such as strong leadership, providing trainings, addressing workflow concerns and advocating related policy changes. (Poon, Blumenthal, & Honour et al. 2004). Currently, Canada Health Infoway ( 2016) has promoted CPOE implementation among health care organizations across Canada. For example, North York General Hospital in Toronto has partnered with Canada Health Infoway to develop CPOE systems and share the order sets freely ( Zeidenberg, 2013). With public awareness of the CPOE gradually increasing, now most physicians recognize the positive impact of using CPOE system to improve patient safety , and they are willing to accept the application (Jung, Hoerbst, & Massari, et al. 2013).

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

This standardized dialect is also pertinent for medical schooling and teaching in addition to clinical research and studies conducted by scholars, scientists, and physicians by providing a valuable foundation for domestic and coast-to-coast operation evaluations. CPT is used to describe doctor’s services, a vast amount of administrative services in addition to operating services executed in medical facilities, treatment care centers, and outpatient divisions. Providing support for clerical duties and functions such as processing medical claims and initiating strategies and procedures for the evaluation of clinical care is another cause of relevance for CPT. The system also meets the need for tracking trends and identifying improvements, plus progression goals and scaling the value of healthcare services received by patients. The CPT coding system provides physicians throughout the United States with a consistent method for classifying and coding clinical procedures which in return provides a more efficient tool for recording and reporting task that were completed. Physicians, scholars and payors, have been dependent upon CPT to interconnect with other fellow associates, patients,

This article discusses how the implementation of the new ICD10 codes are costing more than originally planned. All practices are required to use 2014-certified electronic health-record technology in order to receive funding from a federal electronic health record incentive program. The new estimates for the ICD10 implantation include the cost of such things as education, IT and documentation

Lastly, in the surgery theatre, misidentification may happen due to the same factors formerly mention plus failure to mark site/side of surgery, failure to properly perform time-out, and multiple surgical teams (Chan et al., 2010). To analyze the risk for these errors, few factors will be analyzed including human factors (staffing, scheduling, supervision, and qualification), equipment and technology (scanners, computers, and software), Communication (between staff and patients, between staff, between staff and physician, between physician and patient, and between units), environmental factors (physical, safety, security, and preparedness), and procedures and policies (planning, staff education, patient education, protocols, patient identification, and patient observation) (Chan et al., 2010).

Use at least two patient identifiers when providing care. Double checking of ID bands and ID/Driver’s license of patient if possible. Using labels to mark all materials /items needed for the procedures. A two person check off procedure must be implemented. Items requiring labeling include: patient records, signed consents, and all assessments, diagnostic tests and x-rays. Also included should be any item that is needed for the procedure (blood products, devices, and equipment). Using a matching system, so that all items in the procedure area are matched to the patient. The matching system must be completed by a minimum of two staff members. These staff members should include a qualified staff member, nursing staff involved in the procedure, recovery room staff, and discharge staff.

All these priorities focus on the national patients safety goal as the most important in patient management and treatment, and guide the hospitals toward appropriate policies and protocols to follow and to minimize any possible mistakes or patients harm. I choose the priority focus area of Communication to discuss the current compliance status of our organization concentrating on the standards, which did not meet the Joint

This communication is to inform our fellow team member and most especially the physician groups about the intention of the organization to implement the Computerized Physician Order Entry (CPOE) system. The CPOE application will enable our physician provider to enter order directly into the computer system, the CPOE system will replace the old method of order entry that include, written, verbal order/telephone order, and fax. The CPOE system will enable physician to enter specifications about order such as, laboratory, medication, radiology and special procedure orders. Additionally, CPOE offers some the features of the Clinical Decision Support (CDS) at the point of order entry by recommendation dosage calculations, interactions with other medications, and warning of allergic reaction notifications with alternate medication

This style of documentation standardizes the communication between the health care team, providing information and a sequence in which both parties know what to expect. The format allows data to be recorded in for basic categories which include Situation, Background, Assessment, and

In this article, the authors investigated the vulnerabilities in emergency department to internal medicine patient transfers through self-administered surveys of all emergency medicine house staff. More specifically, the survey investigated adverse events due to faulty communications during handoffs. According to this survey, 29% of the emergency staff reported either an adverse or near-miss event due to errors during handoffs. Furthermore, the survey respondents identified inaccurate or incomplete information, cultural and professional conflict, crowding, and many other factors as the contributors to handoff errors. By identifying specific contributors to handoff errors, this article serves as guidance for handoff intervention.

To improve healthcare in America, the Obama administration passed a law under the Health Information Technology for Economic and Clinical Health Act, to encourage the widespread use of Electronic Health Records (EHR). Under this act, Clinicians and hospital would receive incentives and reimbursement for the effective used of EHR in their practices. Electronic Health Records is an electronic version of a patient’s medical history that is maintained by the health provider over time. It includes relevant clinical data that is pertinent in improving quality of care, reducing medical errors and potential health care cost. For the purpose of this paper, two functions of EHR will be discussed: Computerized Physician Order Entry (CPOE) and Clinical Decision Support (CDS) tools. These two support tools have the potential to greatly improve quality care and to reduce health care cost.

Six risk indicators for not meeting information systems outcome were identified in this study. They were no access to accurate and appropriate information, failure in monitoring mechanisms, not reporting clinical incidents, insufficient recording of residents’ clinical changes, not providing accurate care plans, and communication processes failure. No significant association was found between failing information systems outcome and the types of information systems to be used, either EHR or paper records.

In Stage 3, enhancements to the UMUC Family Clinic business process will be proposed by recommending HIT (health information technology) solution, consisting of a certified EHR (electronic health system)/EMR (electronic medical records) system. Once this system is implemented, it will immediately improve the current process. Customer complaints are high, and the focus is on the long wait times and redundant processes when a patient arrives to be checked in. Moreover, some nurses are not readily available, because they are preoccupied with other administrative duties within the practice. Inconsistent record keeping practices lead to additional time searching for patient records. A HIPPA violation may be detected if a patient’s record is misfiled or lost; henceforth, creating a need for supplemental time and possible duplication of another medical record may be required. This process can be greatly improved by the HIT solution using a terminal loaded with the EHR solution. This will allow patients the ability to enter all of their health record information upon their arrival and that information will be instantly available to the nurses and doctors. This process will also give the patient the opportunity to validate the information and make any necessary changes (benefit information, addresses, phone numbers, and medications).

As many know there is a difference between inpatient facility and a physician’s office. First notable difference it the type of care that is provided and the setting in which care is provided. In addition to the level of care provided there is a difference in the paperwork and the names of the paper work are different (Gartee, 2011). Although there is a difference in the names of the documents used to collected medical information this information is essential to both care providers within outpatient and inpatient settings. They need to use this information to make management decisions in how they will proceed in providing patient care (Bhatia, 2015).