Providing Quality Healthcare of Inpatient and Outpatients - Term Paper Example

?Providing quality healthcare is extremely important for both inpatient and outpatients as the reputation of the hospital is at stake. While the medical fraternity is responsible for the health of the patients, the hospital administration also plays a crucial role in providing quality healthcare as they take care of the billing, documentation of patient health record and all the other required processes during their stay at the hospital up to the discharge of the patient. The healthcare information of a patient is a legal medical record which is maintained according to regulatory, professional, legal and accreditation standards of a healthcare organization as these standards may vary according to state statutes and laws (“Update: Maintaining a Legally Sound Health record- Paper and Electronic”). A recent technological advancement that is being used to maintain the medical records of a patient in a hospital setting is the electronic medical records (EMR) that has gained immense support worldwide. The EMR has several advantages such as improving the quality of health care afforded, reducing expenditure, and increasing work efficiency. However, while the system imposes several challenges that need to be overcome, understanding why and how these systems function would help alleviate some major hurdles (Roney). Medical records need to be maintained for inpatient, outpatient and emergency patients either in paper or in electronic format. These records generally include the demographic information of the patient along with the medical history and the current medical information and status of the patient. Information regarding the surgery procedure if any should be included along with the medications prescribed and other instructions given to the patient. Maintaining health records of a patient in the electronic format has become more commonplace in the recent times as it has proved to have increased efficiency, reduces the time spent on data entry and is also more manageable compared to paper work. Most of the guidelines used for paper work can be applied to electronic entry and there are also some additional safety and legal guidelines to facilitate the effective use of the EMR’s in the healthcare industry. At the onset the system used to run the EMR should be reliable and accurate with clearly outlined procedures for using the system. In addition, the use of EMRs also warrants routine checks on the efficiency of the system and suitable controls need to be used for checking all the patient related information entered in the system (”Update: Maintaining a Legally Sound Health record- Paper and Electronic”). The electronic format offers certain advantages as the entire process can be automated, authenticated and restricted for use through the use of codes and passwords and each entry should contain the name of the employee who entered the information as different individuals may enter the data for a patient. This step will help to ensure the identification of any errors that may have occurred during the documentation process. The EMR also enables the user to track changes in order to correct a wrong or invalid entry (“Update: Maintaining a Legally Sound Health record- Paper and Electronic; Legal Medical Record Standards”). The security rule under the HIPAA includes all the standards and measures to protect the PHI of an individual in the electronic format (“Medical Record Privacy”). Confidentiality of the medical information of a patient should also be maintained according to the HIPAA and any disclosure of patient related information should have the authorized consent of the concerned patient. Hence proper implementation of the EMR can bring about potentially effective changes as it can improve the quality of healthcare afforded to the people through safe and customized processes (“Update: Maintaining a Legally Sound Health record- Paper and Electronic”). With increasing changes introduced in the healthcare system use of paper to maintain health records of a patient is highly difficult. Filing, retrieving files and re-filing, searching and sharing of data between departments and maintaining all the information has turned into a humungous task. In contrast the electronic system is a more powerful, easy-to-use, reliable system that reduces practice expenses, increases effective working of the employees and billing accuracy thereby contributing to patient satisfaction. The system is also cost-effective compared to the manual process and a high quality of documentation is possible which is also consistent. The information stored in an integrated system can be shared more easily among the medical fraternity that could in turn help in managing health risks as it saves time and also reduce costs (“Benefits of EMR”). With regard to error reduction compared to the manual process, a study that examined the use of EMR in a primary healthcare setting found a reduction in errors was observed in the physician-chart interaction and physician-nurse interaction domains and the study attributed these findings to the positive effects of using EMR (Singh et al 238). As these records are more complete they can be effectively and quickly audited. They can also easily conform to regulatory and legislative changes compared to the paper format which is labor-intensive and expensive (“Benefits of EMR”). However, EMRs also have their share of drawbacks like any other technology which is in its early phase of adoption. The research study that analyzed the effect of EMR in a primary healthcare setting also revealed that in addition to the various positive effects, the system also had certain potential disadvantages which were required to be overcome in order to increase the overall effectiveness of the system. One of the major areas that were affected was in the assessment of patients. The EMR allows direct entry of data by clinicians and staff that actually helps to reduce the transcription costs. However, in the study conducted in a primary healthcare setting found that as the physicians were required to take the computer with them during patient assessment, greatest vulnerability was found in this domain which could be attributed to the increased physician interaction with the computer rather than the patient. Hence, any interventions that occur in a complex adaptive system needs time to stabilize and with the combined effort of the central attractors the EMR process can ensure maintenance of hospital medical records in a more safe and stable manner (Singh et al 240). While introducing newer interventional strategies greater care needs to be exercised in training people to adapt to the new technology introduced. More so it is also vital to understand any possible vulnerability that any new system brings with it and this should also be shared with team members within the organization. Valuable inputs that could help in solving these vulnerabilities can be obtained from the healthcare team as well as patients, their families and from financial and other related organizations (Singh et al 236). In any hospital setting it is extremely vital to actively involve all members of a team in order to provide the best treatment and care to the patients who would be the ultimate sufferers if things do not work out. It is necessary to ensure that all the team members imbibe qualities such as mutual trust, respect, collaboration and cooperation in addition to having a shared opinion about providing quality healthcare for the patients. It is important to make note of the hazards that occur during implantation of new strategies such as the EMR so that suitable alternatives can be incorporated to alleviate the hazards. Though recent studies have noted reductions in the vulnerabilities that existed previously, constant reliable monitoring of new technologies like the EMR should be done to indentify new problems that can arise while introducing and implementing the process (Singh et al 236). While it is definitely challenging to implement new technologies and put them to meaningful use especially in sectors like the healthcare, the changing healthcare environment would hopefully help in best utilization of these newer systems. Use of electronic technologies in a meaningful way was stressed by Dr. Farzad Mostashari during his address at the CMIO Leadership Forum. As an initial step for putting the system to meaningful use, Dr. Mostashari stressed on the importance of collecting and using patient related information that would help in patient health management and to improve the overall quality of healthcare afforded. In addition he also emphasized on the need to concentrate on why and how a system is being used instead of merely knowing the manual to run the system. When any newly introduced system is understood in depth it would pave the way for further advancements. According to Dr. Mostashari, understanding the utility of every single feature in the system and analyzing whether it would really be helpful for the patient is the way to put the system to meaningful use. This would in turn contribute to increased work efficiency and quality output. In addition, quicker and effective systems would also help in effectively reducing the cost without compromising on patient healthcare (Roney). Works Cited AHIMA e-HIM Work Group on Maintaining the Legal HER. “Update: Maintaining a Legally Sound Health record- Paper and Electronic.” Journal of AHIMA 76, no.10 (November-December 2005): 64A-L. “Benefits of EMR.” Medical Systems Development Corporation (8 November 2008). Web. 1 December 2012. http://www.msdc.com/EMR_Benefits.htm “Legal Medical Record Standards.” Corporate Compliance Policies and Procedures 2008. Web. 1 December 2012. http://www.ucop.edu/ucophome/coordrev/policy/legal-medical-record-policy.pdf “Medical Record Privacy.” Electronic Privacy Information Center (n.d). Web. 1 December 2012. http://epic.org/privacy/medical/ Roney, Kathleen. “Meaningful Use is Up to You: 4 Key Points from Dr. Farzad Mostashari”. Becker’s Hospital Review 8 October 2012. Web. 1 December 2012. http://www.beckershospitalreview.com/healthcare-information-technology/meaningful-use-is-up-to-you-4-key-points-from-dr-farzad-mostashari.html Singh, Ranjit et al. “Estimating impacts on safety caused by the introduction of electronic medical records in primary care.” Informatics in Primary Care 12 (2004): 235-41. Print. Read More