Implementation of an Electronic Record System in the Hospital Settings - Essay Example

• Computerized physician order entry - provides efficiency for the treatment of patients by sending the necessary instructions specific to the staff who can provide the service (e.g. laboratory services for a pneumonia patient), decreasing time and effort spent in delivering instructions in person (Amatayakul & Lazarus, 2005)
• Medication reconciliation – a collation of a patient’s complete medical records including dosages of all medications are stored, and the data can be used by the next physician that would be providing patient care for the patient (Green & Bowie, 2010)
• Computerized prescribing – lesser errors in prescription can be avoided by typing the prescribed medication instead of writing on pen and paper, and this can be integrated with other systems such as medication reconciliation for easier access (Green & Bowie, 2010)
• Clinical decision support – system is able to assist the clinician in choosing the best course of action for patients by using integrated rules based on clinical data (Amatayakul & Lazarus, 2005)

Using the clinical decision support system as an example, a physician could assess a patient’s disease and progression by using a program that is able to find the most possible diagnosis by combining all possible symptoms that a patient has. It would be much faster than collecting information from different sources such as medical books that are not frequently updated. A possible problem in using this system would be the need for regular updating of the database of the diseases due to new information being generated about the possible symptoms and complications of each disease. This can be overcome by the merging of information technology experts as well as medical practitioners in uploading the new information regarding diseases, new symptoms, other complications, etc. to the disease database (Amatayakul & Lazarus, 2005).

Possible needs assessment for the clinic scenario

• In the given scenario, physicians specializing in internal medicine would benefit a lot in the implementation of an electronic health record system, especially when it was a given that they operate at three different locations and that patients would often come to at least two of these facilities.
• Possible needs of the physicians and staff in this hospital group would be the ease of access to the files of their patients, also the simplicity of the working interface of the program in order to reduce time in finding different files. The accessibility of the patients’ files in all three locations is also a concern for most of the staff.
• One concern would be the acceptability of the user interface of the electronic health record system, especially since some of the physicians are adamant in using computers and would rather rely on actual paper files. The program must therefore be easy to use for all concerned staff to increase its satisfactoriness.
• Advantages of electronic health record system over paper medical records (Amatayakul & Lazarus, 2005):

Privacy – unauthorized people cannot access the system since only physicians and staff with passwords to the system could only see the data, and problems with other patients seeing other’s data by accident are minimized.

Security – only authorized personnel can use the system by logging on using their usernames and passwords, and using a database makes patient records even less accessible as compared to paper medical records that are in danger of being misplaced.

Legal aspects – malpractices can be minimized since the records for each patient are stored and the physicians and staff can look over these files every time they need to check and recheck the course of actions that they do for each step in treating the patient.

Possible project proposal for the hospital in the given scenario

• A team for the implementation of the electronic health record system may be composed of two groups of personnel:
• Hospital’s physicians and staffs – check and recheck information being loaded into the system to see the reliability especially the integrity of the patients’ data, tests the software being developed in each stage, gives go-signal for the use of the system
• Informatics experts – designs the software, checks if the system is able to hold as much data as needed, performs updates and increases database memory as necessary.
•  A trial can be made and problems that may arise can be reported by the hospital’s staff, and the problems would be resolved by the informatics experts as needed.
• One major benefit that can be gained from switching from paper records to electronic records is the reduction of costs in maintaining files, generating copies for patients, physicians and the facility, as well as reducing the number of personnel needed to maintain the files and transcribe the physicians’ notes (Amatayakul & Lazarus, 2005).

Possible electronic systems for different settings:

1. Hospital – database for the patients, their personal and medical information
2. Nursing home – an alert system for providers in administering their patient’s medication
3. Dental office – electronic record system for their patients’ dental records, including all procedures done in their teeth as well as other consultation records