Using computerized electronic medical records management systems will provide nurses and patients with increased quality of care. Because electronic medical records are quantifiable, data from existing and previous patients sharing the same medical condition and/or characteristics can be researched to determine the best care plan and outcomes for the patient, such as what methods of care were practiced, which medications worked, which therapies were most effective, etc.
This enhances not only provides better quality of care to the patient, but also enhances evidence based practice (Thede & Sewell, 2010). Another benefit of using an electronic medical record management system is that all patient information is accessible from multiple locations, and by multiple members of the care team at the same time. Prior to availability of computerized records, patient data was only available in paper hard copy, typically kept in one paper chart, which made it impossible for each member of the care team to access needed data in a timely manner.
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Access to an overview of the patient’s current state prior to face to face meeting with the patient allows the practitioner more time to implement and treat and less time reviewing the case in the patient’s presence. With the ability to view electronic records prior to visits and assessment from each member of the health care team, more efficient planning and implementation of interventions for the patient are achievable, leading to quality care (Thede & Sewell, 2010). Active Nursing Involvement
Active nursing involvement in the planning, choice, and implementation of an electronic medical record system is key to its success within an organization. Nurses participate in initial testing and development of the system, and through that testing, can determine the system that best meets the needs of the nursing role and responsibilities. Nurses are professionals with experience and knowledge about the workflow and expectations of the nursing role and generally have a broad scope of practice within the nursing role, and the knowledge of how nurse workflow and expectations would translate into documentation and flow sheets.
The involvement of nurses is critical in order to allow the most thorough and comprehensive development of the system and maximize its capabilities to meet the needs of each department. All areas of work must be addressed within the electronic medical record system, otherwise, the system fails, so it is in the best interest of the organization implementing the system, to involve and solicit ideas and solutions from the nursing staff in order to ensure comprehensive development of the system (McIntire & Clark, 2009). Handheld Devices Use of handheld devices with electronic patient diaries can improve the quality of patient-reported information collected in clinical and research settings. ” (Hardwick, Pulido, & Adelson, 2007, p. 251) Handheld technology improves patient care by allowing the clinician the ability to efficiently capture patient data at the moment the information is given by the patient. This eliminates the need to take hand written notes, then transcribe the notes into a paper chart which could facilitate error, or inaccurate capture of the data.
Having accurate data is vital to evidence based decision making (Hardwick et al. , 2007) Not only do handheld devices improve the quality of the data captured, but they also lend to increased data capture, or increased documentation when compared with paper charting. This increase in documentation leads to more data on which to base clinical decisions. Handheld capabilities with EMRs improve documentation, reduce medical errors and improve decision support (Wu & Straus, 2006). Barcode scanning is a form of handheld technology used in conjunction with EMR systems.
Use of barcode scanners with medications greatly reduces the number of medication errors by ensure the right patient, dose, route, time and medication are being administered (Patterson, Cook, & Render, 2002). Barcode scanning of medications also proved to streamline the work of nursing and improve nursing care of the patient by allowing the nurse more time to focus on hands-on patient care and other professional activities instead of spending so much time documenting medication administration (Eric et al. , 2008). Security Standards
Personal health information is more vulnerable to breaches in confidentiality, so enhanced security measures are essential in order to maintain patient privacy. According to Deborah Shelton, reporter for the Chicago Tribune, “Computer hackers are looking for specific data. … Today, medical data are among the most sought-after data for committing fraud. ” (2012) It is imperative that electronic medical records systems have proper firewalls and encryption in place to protect data from being accessed by unauthorized users. However, it is not only the outside computer hackers that pose a threat, but authorized users of the system as well.
All patient information is available in just one click of a button, so employee trustworthiness is critical. Employees must be conscientious and aware when accessing patient records, and should never share passwords, or walk away from their computer without logging out of the system. Proper training and education to the staff is a key element in maintaining security standards. Supervision and tracking of employee activity in the system should be practiced as well as discipline to employees who do not comply with security standards.
In an effort to ensure unauthorized people are not accessing data, biometric authentication such as fingerprinting, voice analysis, and signatures can also be implemented (Krawczyk & Jain, 2005). The Health Insurance Portability and Accountability Act (HIPAA) enforces standards and safeguards that protect patient confidentiality and have put forth specific measures for security practices. Although private entities have the freedom to choose their own security systems and capabilities, the electronic medical record system must comply with HIPAA policies.
To do this, HIPAA has established a 10-Step process for companies to use to ensure compliance and security standards are met (http://www. healthit. gov/providers-professionals/ehr-privacy-security). Data back-up and recovery is critical in the event of a disaster such as flood or fire, and also theft of a physical system. Adequate recovery and backup services must be available in order to ensure preservation and security of patient data. Multiple data backup programs should be available to the EMR system, and the backup and recovery of data should be tested prior to implementation of a live system (Smith, 2003).
Cost A study analyzing cost effectiveness of use of electronic medical records published by The American Journal of Medicine concluded that implementation of electronic medical record systems in the primary care setting resulted in a very positive financial benefit. The net benefit from using electronic medical records over a five year period averaged over eighty six thousand dollars per provider studied. Those benefits come from improved utilization of testing, better charge capture and a large reduction in billing errors due to the office management capabilities found in electronic medical record systems.
Additional areas analyzed that showed a cost savings were: reduced need for transcription services, chart pull cost elimination, and prevention of adverse drug events (Wang et al. , 2003). Benefits to Care EMR systems offer numerous benefits to patient care. Having access to electronic medical records eliminates “per incident” paper charting, which gives the nurse an overall view of patient’s case including past medical and surgical history, current medical conditions, laboratory results, test and imaging results, physician and nursing progress notes, therapy notes, prescribed medications, and patient care goals.
Use of an EMR also saves time by giving the nurse that comprehensive view of all needed patient information in one place, allowing the nurse to spend more time doing direct hands-on patient care. Utilization of EMR systems also fosters evidence based practice by lending to ease of research to view past medical data, care plans and outcomes of patients with similar health issues. Having access to this information in an efficient manner allows the medical team to more effectively treat patients based on similar cases (Thede & Sewell, 2010). Recommendation & Justification
In doing my research, I compared two electronic medical record systems: Sunrise Clinical Manager 2011 Suite 5. 5 and ADP AdvancedMD HER. Based on my findings, I recommend the ADP AdvancedMD HER system be implemented. ADP AdvancedMD is supported by the internet, so remote access is possible from anywhere the internet is available. This will allow for greater flexibility for physicians and the other members of the healthcare team. ADP AdvancedMD also caters to all medical specialty areas from dermatology, and cardiology to pediatrics and general surgery.
Its capabilities are adequate for a variety of clinical settings and any practice size, and there is no limit on the number of physicians the system can accommodate. ADP AdvancedMD also includes many practice management features such as appointment scheduling, document management, electronic billing, and task management and templates. Important security features with ADP AdvancedMD include automatic backup, automatic logoff, encrypted data transfer, password protection, recovery protection and person authentication.
All of which will allow the facility to comply with HIPAA safeguards and regulations. ADP offers various training options be it individual or group in-person sessions, or virtual training by use of training videos and online tutorials. IT support is accessible all hours by phone or email. Implementation of ADP AdvancedMD will enable our institution the greatest benefits related to electronic medical records as previously discussed. This system will also allow our institution to streamline office management practices, save time and cut costs by use of the many applications available.
Support is adequate and security measures included with this system will ensure protection of patient data and information, and will also allow complete compliance with HIPAA safeguards and regulations. ADP AdvancedMD guarantees a return on investment to users, ensuring cost effectiveness. This system is hands-down the best system reviewed and offers the maximum benefit to the user. I recommend implementation of ADP AdvancedMD electronic medical records system.
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