Electronic Documentation in Health Sector - Research Paper Example

? Electronic Documentation in Health Sector Electronic Documentation in Health Sector Literature Review There is the need in the modern day practice to embrace information technology and advanced nursing practices in order to realize the current as well as future nursing needs within the society. Health care record keeping by electronic means is a basic tool to be exploited to address the rising complexities within the nursing field. In a study to investigate the barriers to adoption of a standard language in the nursing field, data were collected through surveys, which were administered to a random respondent group established by a computerized mechanism of the practitioners who practice within the ambulatory health systems in the US. The descriptive statistics was evaluated through SPSS through which the correlation indices to the factors under analysis were sought and later interpreted. The outcome of the analysis has revealed the perception of the interviewees that nursing care information is often omitted from the records mostly because of three reasons: no easy documentation method, a failure to reimburse the nursing documentation as well as little time to document. The basic tool to overcome the constraint was seen to be the adoption of electronic mechanisms of documentation, which equally relied on availability of technology and its adoption. Therefore, the relevance of the research study by Conrad and the team to my capstone project is that it affirms the need to embrace technology in documentation of nursing practices for the ease and efficiency of retrieval of the health records (Conrad et al. 2011). Information technology has been seen to be a critical component in the modern day communication between practicing medical staff and the patients. Besides the necessity of the effective communication to bring about satisfaction to patients in the medical procedure, the lack of it results in great failures within the field. In a study to analyze the role of information technology and the assisted communication within the medical field Angst and colleagues adopted the mode of structure and process as well as outcome, to carry out the analysis. The research was informed by the limited literature that existed on the role of information technology when integrated in communication-based transactions within the medical field. It adopted a SPO framework (structure-process-outcome) to test technical as well as interpersonal care processes within the medical field. IT was found to serve in both interpersonal as well as technical processes in the medical field. This is because clinical IT affects the technical dimension while the administrative IT impacts the interpersonal patient care dimension. Measures of hospitals performance are often based on the technical competence as well as the patient’s satisfaction. The structure, according to this research, was found to imply not only the physical organizational structures, but also the incorporation of IT into the management practices. The research, therefore, served to affirm the necessity of health practitioners to embrace technological changes for the purpose of efficiencies in processes and practices (Angst et al, 2012). This study, therefore, has concluded that medical health managers should be aware that underutilization as well as the overutilization of IT in the field would be disastrous to the overall outcome of the institutions. Stored medical and clinical data have many uses among which are clinical care as well as purposes of research. Jensen, Jensen and Brunak (2012) sought to study the critical necessity of proper data storage for the clinical data to be used for research studies as well as for better clinical care. Phenotype information as well as patient information within this field stands to have a great significance though it is often little utilized. Information technology has greatly revolutionized the practices of capturing, storing as well as retrieval of information regarding medical and clinical practices. Through extensive literature review, the study has found out that the adoption of information technology within medical and clinical fields has been intensified. However, there are notable challenges that characterize the practices such as cost factors in integrating the nationwide database as well as constraints in technical knowhow. However, as the study postulated, the proper handling of stored information in the medical field is very critical for furtherance of research as well as for improvement of the clinical care for the future. This, therefore, confirms the need for the adoption of improved systems to be used in collecting, storage as well as for retrieval and sharing of these data. Information technology adoption in the field is a basic and most effective tool to be exploited for this purpose. However, one challenge that stands to be overcome and which has always posed problems in the effectiveness of electronic systems of data management within the discipline of medicine is missing databases or disorganization of the databases in use. Researchers often rely on the analysis of the stored information and as such, the inconsistency or missing information needs to be overcome through the appropriate methods in order to realize a full efficiency. From the findings of this research, improvement to the electronic methods of handling and storing data in the clinical field is fundamental for efficiency not only in the medical service delivery, but also in furthering research. Modern trends in the medical field have necessitated transformation of primary care into medical homes which are patient centered (PCMH). There are, however, diverse opportunities as well as challenges associated with this practice of transformation, and it attracts different opinions and perceptions from the practitioners. In a research study, Arar and others sought to study the practitioners’ perceptions concerning this practice. Interviews in a semi-structured manner were conducted targeting practitioners in small primary community based care practices from which findings were analyzed. Two main fields of concern in the process of transformation were noted: the involvement of patient in the management of their diseases as well as the overall process of care. Among other pointed out concerns in the care process is the improvement in documentation processes, tracking and follow-up of patients as well as the process standardization among others. The priority in transforming the primary care among many practitioners relies heavily on the modernization practices, which are cognizant of the importance of technological advances. Among the identified internal as well as external barriers noted to inhibit the process of transformation, rigidity in process adoption and education levels stood out much. Difficulties in good relations between team members, the resistance to change as well as poor communication inhibit the change in management practices pertaining the adoption of technology within medical organizations. Thus, there is a need to embrace higher educational standards in the medical field which will aid the incorporation of technology within the practices adopted (Arar et al, 2011). This equally contributes to my research capstone in supporting the past literature in the need to embrace change in the clinical management and adds to available literature through affirming the need for structural adjustment for efficiency and effectiveness in the adoption of IT in record keeping practices. Modern trends in medical practices have seen the adoption of technology revolutionize from the basic practices into which computerized practices of transmission of information were initially adapted for to the more complex uses such as the automation of medical records. An electronic health record system is a focus of many practitioners in the field due to the numerous notable advantages of the practice. The EHRs increases the information availability, changes clinical workflows, changes documentation processes as well as provides opportunities for innovation. Bonnet (2010) undertook a study to understand the risks involved in compliance with the actualization of EHRs in the medical practice. Privacy as well as security in the management of electronic health records forms a basic consideration in implementing the desired EHRs. Besides, the compliance to an organization’s policies as well as government policies forms another area of focus from the management before settling for specific EHRs. Through analyzing other literature, Bonnet confirmed the need for the adoption of technologically effective mechanisms for documentation processes within the practicing profession of medicine. However, the findings of the report were that as a tool, IT is only as effective as it is adopted in accordance to the institutional frameworks that work for it and, hence, there is the need for preparation before its adoption. Change is a basic component to any person’s life including profession as well as to the organizational structure. EHRs have brought a great change in the electronic documentation process involving the current and past records of patients. The electronic documentation is effective in patient personal demographics, laboratory information, billing information as well as referrals information. Besides being critical for practitioners of the medical field, the electronic documentation practices are instrumental in shaping other fields related to medical professions such as the legal nurse and consultation. In 2011, Wolf and Nellis sought to evaluate the necessity to help the Legal Nurse Consultants to adjust into the use of electronic record systems. Among other notable benefits to be realized were the management of multiple tasks, the use of alerts and reminders that assisted in prioritization, lowers levels or redundancy in documentation, help in a quick access and retrieval of information as well as the reduction of the occurrences of errors. Through the evaluation of the literature, the study established that the traditional means of record keeping was tedious and time consuming and often suffered inefficiencies brought about by illegibility of the writings and misplacement of such records. Therefore, the adoption of electronic means of handling medical information is interpreted to bring about efficiency, quality as well as safety. It brings about effectiveness and efficiency in medical data storage and retrieval in that it is recorded once and can be easily retrieved ever after. Nevertheless, there are challenges that the practicing lawyers must be aware of and as such be prepared to face them in the process of adoption of the electronic documentation. LNCs must, therefore, be proactive in understanding the processes involved in implementing and the working of the electronic documentation processes (Wolf and Nellis, 2011). Labor costs in billing and insurance constituted the great burden in the overall costing within the US health industry in the past. However, the recent past has seen the adoption of policy frameworks among which are geared towards lowering the costs incurred in management processes such as documentation among others. Through the Office of the Secretary of States in the US, necessary policies and acts have been formulated to empower and encourage the medical practitioners to adopt the electronic methods of documentation as one of the mechanisms aimed at addressing the cost implication in handling the health records. Operating rules on EFT and ERA are formulated to bring about efficiencies in health care administrative tasks such as in storage, access, and retrieval of information and records. Therefore, according to the report by the Secretary of State’s Office, electronic documentation is the way to go in order to realize the outlined benefits and efficiencies within the health sector in the country (Office of the Secretary, 2012). Financial incentives have been set to encourage medical practitioners to adopt the electronic methods of documentation, which equally outline the non-conformity disciplinary actions. However, there are basic fundamental factors that influence the acknowledgement of the incentives among the independent health practitioners in the country to adopt the electronic methods of health record keeping. Sherer in 2010 researched possible factors that had the likelihood to influence the expected reactions among the practitioners towards the incentives set to encourage them to adopt the EHRs. The study adopted the use of “theory of institutional forces” and as a result developed propositions to be used in the future research. The study also used models to examine the coercive, normative as well as mimetic forces that were influential in the bid. Dominant health care partners in the delivery of services as well as the penalties to be suffered represented the coercive forces influential in the experiment. The expected outcomes in the adoption of the electronic mechanisms of documentation exert the mimetic pressure towards compliance while regional consideration of the adoption of the practices exerts the normative forces. Therefore, according to the policy framework, communication, measurement, decision support as well as coordination of data in the health field for the basis of electronic documentation process are effectual for improvement of data management practices within the medical field (Sherer, 2010). The study affirmed that the use of such forces as coercive, normative as well as mimetic influences the cooperation of medical practitioners with the adoption of electronic methods of data collections, storage, and sharing. The interactions between the patients and health practitioners are influenced by electronic health record systems in use. Drug-drug interactions often result into adverse effects, which are resultant from the unmonitored drug use. Electronic medical record database forms a very effective tool for monitoring evaluating as well as predicting novel DDIs. By adopting the use of a reasonable repository sample of patients, Duke and colleagues undertook a clinical assessment for the drug interaction using electronic medical records (Duke et al, 2012). The study relied wholly on data from samples records available within medical institutions. By pairing the occurrences, the study has found out that the drug-drug interactions are the most influential cause to adverse drug events that are mostly experienced. The adoption of electronic database for the research goes a long way in confirming the necessity of adopting electronic mechanisms of data storage as compared to the manual methods. Such clinical experiments and research studies are dependent on the availability and the ease of access of historical data. Electronic documentation, therefore, proves to be the most efficient method of storage of the data as well as the easiest method for data retrieval. This serves to confirm my proposition of the importance of data management through electronic means, which results from efficiencies in storage, retrieval, and sharing of the data among departments as well as research institutions. Nurses and other healthcare practitioners have been in the analysis of their strategic role in the success of health care industry. Among the other ways through which the analysis has been focused on has been the adoption of electronic mechanisms for documentation practices. In the surveillance on children maltreatment in the US, Mugruder ascertains that the past has seen the children protection agencies charged with the responsibilities of documenting the information though the data which notably suffers limitations in scope. The interaction of protective department records as well as the vital medical records proves instrumental in the record keeping and analysis. Efficiency in linked interdisciplinary record keeping systems has, however, received a boost through an electronic documentation process. From the study, it becomes fundamentally true that the departmental data as recorded often suffer limitation. Collection and sharing of data from department to another one through the manual means suffer the great challenge of errors and inefficiencies. However, modern methods of data handling through the electronic means are, thus, the recommendation of the study to address the challenges outlined (Hornstein et al, 2011). Through evaluation of traditional mechanisms that have been in use and their efficiencies the report has established a support to my capstone project by supporting electronic data management practices which will increase efficiencies and effectiveness realized in the data management and sharing between responsible departments. References Angst, C. M. et al. (2012). Dual role of IT-assisted communication in patient care: A validated structure process-outcome framework. Journal of Management Information Systems, 29(2), 257–292. Arar, N. H. et al. (2011). Implementing quality improvement in small, autonomous primary care practices: Implications for the patient-centred medical home. Quality in Primary Care, 19, 289–300. Bonnet, B. (2010). Compliance risk areas associated with implementation of electronic health records. Journal of Health Care Compliance, 6-14. Conrad, D.et al. (2011). Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner. Journal of the American Academy of Nurse Practitioners, 24, 443–451. Duke, J. D. et al. (2012). Literature based drug interaction prediction with clinical assessment using electronic medical records: Novel myopathy associated drug interactions. Literature Based DDI Discovery and EMR Assessment, 8(8), 1-13. Hornstein, E. M. et al. (2011). A public health approach to child maltreatment surveillance: Evidence from a data linkage project in the United States. Child Abuse Review, 20, 256–273. Jensen, P. B., Jensen, L. J. & Brunak, S. (2012). Mining electronic health records: Towards better research applications and clinical care. Genetics, 13, 395-405. Office of the Secretary. (2012). Administrative simplification: Adoption of operating rules for health care electronic funds transfers (EFT) and remittance advice transactions. Federal Register, 77(155), 48008- 48044. Sherer, S. A. (2010). Information systems and healthcare XXXIII: An institutional theory perspective on physician adoption of electronic health records. Communications of the Association for Information Systems, 26(7), 127-140. Wolf, D. M. & Nellis, D. L. (2011). Informatics: Helping the LNC Adjust to Electronic Records. Journal of Legal Nurse Consulting, 22(1), 9-13. Read More