Patient Information System Analysis

In our society today, we have a broad range of computer technology for our use. This technology in the nursing field is called informatics. Informatics is defined as a combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and the knowledge to support the practice of nursing and the delivery of nursing care (Thede, 1). Nearly anywhere we go, and whatever career we choose we all need to have basic computer skills. Computers are used in the health care profession due to an increase of productivity they can provide, therefore allowing for better patient care. Computers also allow for hospitals, doctor’s offices, and other healthcare facilities to change over to and begin keeping electronic medical records (EMR). An EMR has the medical information that the doctors and nurses obtain when you have an office visit. The patient’s paper medical record is put into an EMR program is basically made into a digital version of that patient’s medical information. The patient’s healthcare provider can then use these EMRs for diagnoses and treatment. There can be advantages and disadvantages for healthcare providers to transition to an EMR system, and those providers will have to decide which one will outweigh the other.

In 1996, Congress passed the Health Insurance Portability and Accountability Act, better known as HIPAA. The purpose of HIPAA is to provide guidance and tools to protect and secure patient’s medical records. There are two sections of the act that will be today’s focus – the Privacy Rule and the Security Rule. At the end of this training, employees will understand what HIPAA is, how it applies to [Hospital], and the penalties for violation.

HIPAA requires nurses and nursing students to keep patients’ medical records confidential at all time. For instance, I used computer to review patient’s diagnosis, I made sure that I signed off the computer after using it. I also made sure that all the information I brought home with me did not include patient’s name and other information that identify patient identity.

How would you like to keep track of your personal health information record in your computer at home? The electronic data exchange was one of the goals of the government to improve the delivery and competence of the U.S. healthcare system. To achieve this plan, the U.S. Congress passed a regulation that will direct its implementation. The Department of Health and Human Services is the branch of the government that was assigned to oversee the HIPAA rules. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a national public law in the United States that was created to improve health insurability, prevent insurance abuse and to protect

After adopting the EMR, the facility members are very satisfied and pleased giving patient care. According to few medical assistants, who are working in this facility for long time, they said they don’t know how they handle paper documentation in the past and majority of time they spend was on finding and looking for papers than actual patient care. EMR, no doubt has significantly improve the communication between the healthcare professionals. At every patient encounter, during their each

This paper is intended to summarize the objectives of HIPAA in safeguarding the privacy of individual’s private health information from unauthorized access in general and security requirements for HIPAA compliance in particular. The HIPAA privacy rule requires covered entities to protect patient’s health records and any other identifiable health information by using appropriate safeguard to protect privacy. The HIPAA security rule requires that covered entities implement a security technology to safeguard the integrity, confidentiality and availability of individual’s electronic private health information while exercising quality service for patients. Healthcare providers have shifted towards the use of electronic health records

HIPAA increasingly dominates the nursing landscape. Safeguarding private patient information is not just important. It is becoming more technical with the introduction of Electronic Medical Records (EMR), training on the technology, safeguarding EMR and the complications of outsourcing of EMR management to contractors.

EMR concerns are plaguing the health care industry today that requires change. Healthcare professionals, such as nurses, are on the front lines in the defense against medical errors. Closing the gap between current clinical and hospital practices and the various approaches to improving patient safety requires changes that are cultural and systemic in nature. The greatest challenge to hospitals using an EMR system is the expense of the new system, and the challenge nurses face with technology adoption in usage of EMR and protection of records. Even though spending depends on both the hospital size and the technologies were chosen, implementation and installation of a Health Information Technology system, which includes EMR, are often multi-year investments. The transition from a paper-based system to an electronic system is a very complicated process within every hospital establishment. The transformation is time-consuming and involves numerous staff from across the hospital, including Information Technology personnel, physicians, nurses, ancillary providers, etc. Although hospitals work hard at managing the changes required to move toward an electronic environment, there is no guarantee that hospital personnel will properly utilize the expensive new IT system or EMR. Therefore, the training in the EMR integration is required to all medical staff to have an efficient and uncomplicated system.

Technology has come a long way over the years and continues to advance rapidly. The health care system is greatly affected by the advancements in technology. An example of this would be the use of electronic health records (EHR). In this paper I will be describing the electronic health record system. How my facility has initiated the EHR with following the six steps and describe meaningful use and how my facility is working towards this. Lastly I will discuss how to maintain patient confidentiality with use of EHR, and what my facility is doing to prevent HIPPA violations.

According to McGonigle and Mastiran (2015), EMRs on the surface suggest a simple automation of clinical documentation, in fact their implications are broad, ranging from the ways in which care is delivered, to the types of interactions nurses have with patients in conjunction with

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).

The use of IT in the healthcare field has been a strategic focus for necessary improvement that stands to enable more cost effective, higher-quality, and far safer patient care according to the Committee on Data Standards for Patient Safety (2003). The National quality forum conceptualized the idea of meaningful use to the nursing fraternity and believed that they were the most critical link in patient care and health delivery and hence technology tools of EHR would be best used by them The purpose of the electronic health records was to improve the health of population, coordination of care, safety improvement in patients undergoing critical and long term care, and patient and family engagement in timely access of

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to

Collaboration and communication between patient’s, their physicians and the health care team are required in order to preserve the safety of the patient. Improper use of EHR can produce errors that may possibly threaten the reliability of the information in the EHR which may endanger patient’s safety thus decreasing the quality of care. Healthcare quality relies on the accuracy and integrity of the patient’s health information. One manner EHR accuracy may be-threatened is because of the growth of members of the healthcare team copying and pasting text documentation. The copy and paste process poses a risk to the integrity of nursing documentation. Risk such as, redundant documentation, outdated documentation, and inability to identify when

Along with the patients, the hospital reaps many tangible and intangible benefits from EMR as well. The information in the electronic record is easily accessible to multiple clinicians at multiple locations at the same time, with nearly immediate retrieval time. For this reason, it is updated frequently and is available for access at any workstation whenever the information is required making time spent with patients more efficient (Gurley, 2003). According to Shi and Singh (2003, p. 165), one of the most important aspects of electronic records is the integration of specific patient profiles with clinical decision making tools built into the software which provide evidence-based practice reminders and guidelines for effective, efficient treatment. This type of alert system can result in reduction of medication errors and in appropriate treatment options, saving both the patient and the clinician from harm.