Medical Data And Electronic Medical Records

One of the issues with the electronic systems in health care for MU is the ability to retrieve laboratory results during a patient’s visit. In 2013, Hinrichs and Zarcone reveal that over 70% of medical decisions are determined by laboratory results. In 2007, AU Health implemented Cerner Millennium PowerChart that displays clinical data to improve the point of care for patients. With the PowerChart solution, the patient’s information can be easily verified, vital signs can be entered, and family history can be updated. The Affordable Care Act (ACA) signed by President Obama in 2013 places emphasis on expanding insurance coverage of medical care for everyone. As part of the ACA, the improvements in the way these results are exchanged and transmitted will add value to quality, safety, efficiency of health information (Hinrichs & Zarcone, 2013). The transmission and availability of EHR affect how other health professionals send and receive information at the local, state, and national levels.

Worldwide use of computer technology in medicine began in the early 1950s with the rise of the computers. In 1949, Gustav Wagner established the first professional organization for informatics in Germany. Medical informatics research units began to appear during the 1970s in Poland and in the U.S. Since then the development of high-quality health informatics research, education and infrastructure has been a goal of the U.S. and the European Union. (NYU graduate training program, 2010) Changes in the healthcare environment produced fundamental shifts in the delivery of healthcare. The altering landscape of healthcare is creating a huge demand for health data analytics. The growth and maturity of healthcare informatics over the past decade has been a prime catalyst in positioning the healthcare industry for the changes posed by reform measures. By understanding the process of analytics, clinical informatics specialists say healthcare providers have the insight necessary to make the process adjustments in the future.(Riskin, 2013)

In order to meet the requirements set forth by the Federal Government many health care institutions began the painstaking process of seeking out an electronic program. These institutions sought to purchase a system that would have the capacity to interact with other programs, and the flexibility to allow all clinical personnel easy access to pertinent medical information such as labs, diagnostic test results and past medical history.

In recent years, there has been a growing interest in the application of biomedical informatics in many aspects of the healthcare system. This is due to an increasing recognition that a stronger healthcare information system is crucial to achieve a higher quality care at lower costs1. Biomedical informatics is defined as “the scientific field that deals with biomedical data, information and knowledge-their storage, retrieval, and optimal use for problem solving and decision making.”2Biomedical informatics plays significant roles in the healthcare system and it has been applied in various ways in the healthcare system, specifically in the aspect of health care information system such as electronic medical record (EMR), personal health record (PHR), computerized provider order entry (CPOE) systems, bar-coding medication administration systems, telemedicine, telehealth, and administrative information systems 2.

While many people believe that health information exchange is a relatively new thing, it has been around for over four decades. However, in the beginning phases it was nowhere near as complex as it is now. Sometime in the middle of the 60’s, an early form of a data processing system was formed and it focuses on clinical data management. This system began to catch on even though they were nowhere near as sophisticated and or functional as the health records in today’s time.

The task support field has been revolutionized through the implementation of the electronic medical record in conjunction with EPIC. The universalization of the electronic medical record will increase the accessibility of patient information to clinicians as well as increase the amount of data available for clinical use, reducing medical error significantly. However, the greatest tool to increase the standardization of care, reduction of practice pattern variation, successful and effective diagnosis, and correct care path choice will result from the development of Information system facilitating true interdisciplinary care. Clinical Information specialists offer the possibility to improve the quality and reduce the cost of care by influencing medical decisions at the time and place that these decisions are made. Our clinical Nurse Information specialist would alert physicians and Nurses when outlier results are returned from data entry of laboratory testing. The data attained for a specific patient can then be compared to the general population to indicate whether the data is within the normal fit or is an outlier that may require further analysis. Such a practice would induce the physician and Nurses to notice certain data that may otherwise go unnoticed, and therefore, alter the diagnosis of the patient. A physician may enter a possible diagnosis into the system and then receive feedback from

A clinical laboratory is defined as any facility where materials derived from the human body are examined for the purpose of providing information for the diagnosis, prevention, or treatment of disease or the assessment of health. Standards applied to

“By 2015, use of a certified electronic health record (EHR) is mandated under the Health Information Technology for Economic and Clinical Health (HITECH) Act” (Kelly & Tazbir, 2014, p. 129).Electronic health records comes from the electronic medical records data and where nurses document the patient’s care that has the ability to move from one provider to another. “The main purpose of documentation is facilitating information flow that supports safety, quality, and continuity of care” (Kelly & Tazbir, 2014, p. 131). Electronic health records also improves the quality of confidential health information as compared to the paper system. Informatics is defined as “the use of information technology as a communication and information-gathering tool

Automation of information includes computerized physician prescription, computerized physician order entry, electronic medical records, electronic alerts, automated decision support, and electronic capture of clinical data that enables service quality improvement.. With automation comes a new level of challenges surrounding adoption, security, training and integration of standards and systems. Health care is becoming automated. Automation is not limited to the infrastructure surrounding the health care institution. Procedures can now occur with a surgical unit on one side of the world while the

Another development which supports the pathology services is information technology (IT) which connects diagnostic laboratories with clinical, academic, industry and public sectors. Most of the NHS laboratories utilize laboratory information management system (LIMS) to manage electronic requests and reports to communicate with clinicians or general practitioners. The new National Laboratory Medicine Catalogue (NLMC) has a significant influence on the overall healthcare system, including patient safety and quality of diagnostic and clinical data. Although communication between diagnostic and clinical sectors has been improved electronically, full integration and widespread use of data exchange are still developing in some areas. The NHS has

establishments. Hospitals and Healthcare Organizations (HCOs) are no exception. In fact, HCOs have been a sort of trigger for innovative technology directed towards improving the comfort level and safety of patients. In addition, the widespread use of computers has also resulted in getting proper feedback on performance. There has been increasing sophistication of software applications in hospitals and thus Information Technology (IT) is fueling several innovations in medical instrumentation; this is happening in many areas of healthcare including cardiology and radiology. Laboratory investigations such as measurement of cretin, urea and uric acid, lipid

For people with concerns about health issues, the physician 's office is usually the first contact with healthcare. Physician’s waiting room is usually busy with patients of all ages with different symptoms and reasons for being there. With a physician’s competence and medical experience, they know what can be easily cured, what should be followed up, and what needs to be referred to a specialist. The accurate testing of clinical parameters is the key for making important medical decisions. The dominant model of laboratory testing is centralized laboratory, which more of analytical processes are automated to enable the analysis of large numbers of samples at relatively low cost. This

Laboratory medicine and pathology services play an important central role in the provision of healthcare services and are involved in approximately 70% of health care diagnoses (Department of Health, 2008). Most acute hospital trusts will provide pathology and laboratory medicine services through the four main sub divisions - microbiology, haematology, biochemistry, and histopathology departments. Pathology services are fundamental to the running of medicine and healthcare systems and provide a wide-ranging assortment of services to both the local primary care providers and hospitals. Services provided by pathology and laboratory medicine include screening programmes, monitoring the prognosis of diseases, public health and health

A lab technician should strive to deliver consistent, accurate and reliable results in a timely manner at all times. Every lab tech should follow the guidelines and procedures that are in place in the laboratory. Safe, professional and cooperative work environment should be ensured. Standard operating procedures and all parts of the quality assurance programs should always be implemented, to ensure that the most accurate and precise results are produced and the high standards of patient care are maintained 1. Sound judgment should be used when preforming tests and analyzing results, issues should be communicated to the appropriate person. Proper documentation of all procedures, issues, corrective actions should be maintained. Result should never be falsified or discussed with people who are not authorized. The privacy and dignity of colleagues and patients should be maintained and everyone should be treated with the respect.

Public Health Departments or agencies rely on hospitals, clinics, and laboratory data to provide timely intervention in a community when there is an outbreak of disease to prevent additional illness. Because the conventional methods of reporting via mail, facsimile, or telephone require active participation of laboratory staff, automated reporting from clinical laboratories has been proposed as a means to improve the quality and timeliness of disease notification[1].