System and Setting Description
The health care facility, in which the clinical documentation system is going to be assessed in this paper, is a medium-sized specialized clinic with about 150-beds and a relatively big staff of medical and support workers. The clinic is the cancer center treating patients with all kinds of cancer and assisting them with transferring to the survivorship mode. The staff of the hospital comprises executive workers, physicians, nurses, and employees of various support services like financial assistance and lawyers. The clinic is relatively new as it was opened a few years ago, but it has already become popular with patients from all over the states and country. The cancer center is known for the excellence and superb quality of everything it does. One of its greatest advantages is the security of the patients’ data and a guarantee of their safety and outstanding care. Partially, it has become possible due to the clinical documentation system functioning in the nursing workplace setting.
When the center was only constructed, the issue of choosing the most appropriate documentation system arose. The main dilemma was whether to follow the old tradition and rely mainly on the paperwork or to implement innovations and transfer to the electronic health record. Aspiring to make innovation and progress an integral part of the facility’s values, the administration has chosen the electronic health record system. The underlying reason for such a decision was the desire to increase the level of healthcare quality as poor documentation, inaccurate data, and insufficient communication can result in errors and adverse incidents. Some hospitals deem it difficult to break the old habits of operating and switching to the EMR system as it requires much time and resources. Besides human resources like the highly experienced IT specialists, the EMR system costs a considerable amount of money, thus as cost barriers are powerful, it is clear why adoption rates are so slow. However, the potential benefits of the EMR successful implementation significantly outweigh its shortcomings. Besides, it is easier to implement the EMR in a new clinic because its operating is planned already during the construction stage and all hired employees are informed that EMR is to be exploited. The EMR model exploited in the clinic is the two-level modeling or the Adaptive Object-Model.
EMR means that patients’ medical records are accessible, and physicians and nurses do not have to waste time questioning patients about their health history. Electronic data is often more accurate and full because paper documentation can be lost or improperly conducted. Most data is translated into such codes as ICD-9-CM and CPT with the aim of standardizing information. Health information management professionals are responsible for storing and translating data as well as for conducting written and oral queries. EMRs of our patients are accessible only to authorized medical workers in order to ensure their safety and security. One of our clinical documentation improvement strategies is the use of electronic personal health records. Our center exploits linked records, i.e. health-related information can be imported from different sources, for instance, entered by the patient, clinic workers, or imported from pharmacies and medical devices. Using EMR and PHR systems does not relieve our workers from paperwork, but the extent of the latter is considerably smaller than in settings with a traditional documentation system. Concerning the paperwork, it is often color-coded and distinguished in other ways for quicker access and less confusion. Withal, the clinical documentation system is aimed at fulfilling the following purposes: quality of care and treatment, patients’ safety and convenience, integrity and accuracy of data, its operability and fullness, and easy access to it on the part of authorized physicians and nurses.
Data Collection and System Analysis
Data collection is crucial for the successful functioning of the EMR system and increasing the quality of care. Thus, our center follows the practice when data can be entered into the system by different authorized people. Primarily, physicians and nurses are tasked with data collection and input into the patients’ EMRs. Nurses play the role of mediators between physicians and clients assisting the latter with understanding medical terms and other data from their EMRs and PHRs. Despite the fact that physicians are responsible for data collection from check-ups and diagnosing procedures, they do not spend less time actually treating the patients. They just spend more time at their computers than with their paper files. HIM professionals’ role has evolved from managing the content of the medical record to contributing to EMR data standardization and harmonization. Moreover, data may be collected from lab reports, pharmacies, medical devices, etc. This function is possible because the clinic exploits linked records.
The temporal frame of collecting data encompasses three dimensions: retrospective or historical health care, concurrent data, and prospective clinical actions. This way, the EMR system is supposed to provide a longitudinal view of a patient’s health care, from cradle to grave. The data is used by all medical workers who are tasked with caring for the client, starting with the nurse and finishing with the financial accountant helping the client with the bills. However, the clients’ privacy is highly respected, and access to their EMRs and PHRs may be restricted by their request if it is well justified. Only licensed and authorized physicians and nurses can make alterations in the EMRs and PHRs. Data may be easily retrieved on the personal computer of every health care practitioner in our center. Besides, they may enter the center database remotely of they have installed a special program. All the workers are well knowledgeable about the procedures of inputting, reviewing, altering, and retrieving the data from the EMR system. In the beginning, there were some problems with the functioning of the program as all EMRs had to be created from the null. However, nowadays the function operates as intended and is credited with facilitating the treatment process and increasing the quality of care for patients, for instance, a huge number of medical errors was avoided, readmission rates decreased after implementation, average medication administration times were cut from 132 minutes to 38 minutes, and physician order entry reached 87 percent. This way, it may be claimed that the system definitely supports the workflow.
Safety and Outcomes Analysis
The clinical documentation system supports patient safety as they always know who has access to their records. Moreover, they also can view their records and even alter some data in their PHRs. Despite the worries that EMR may endanger patients’ security and safety, it has turned out to be vice versa as electronic records may be accessed only by authorized personnel who have a password to enter the system. In terms of safe care environments, the system has proved to be beneficial as well. More than 100,000 medical errors have been averted thanks to the EMR. Clinicians have fuller and more accurate data at their disposal and can make more valid decisions concerning the treatment. Patients may always follow their treatment process and clarify some points they find confusing or incomprehensible. PHRs play an essential role in the post-treatment period as patients can view when they have planned check-ups, what medicines they should take, and what physician’s recommendations they should follow. With the EMR and PHR implementation, clients have become active participants of the health care process. In this respect, the role of nurses has gained additional importance as they are often the ones who are tasked with making EMRs comprehensible for the patients.
The strengths of the system objectively and as evaluated by clinical workers are the following: improvement of the quality of care, increase of the workflow efficiency, improvement of clinical processes, improvement of data capture, decrease in the number of medical errors, easy access to records by authorized personnel, facilitation of the clinical decision support, improvement of patient satisfaction, creation of safe health care environments, and improvement of employees’ satisfaction. The greatest shortcoming of the EMR implementation is its tremendous cost. However, the return on investment is envisioned to exceed the amount of the business case expected benefits this year. The EMR implementation has not altered the amount of time spent by physicians with patients. However, the work of clinical and office staff changed significantly and included decreases in time spent distributing charts, transcription and other clerical tasks. Another limitation of the system is the necessity to employ IT professionals who are to overlook the system functioning and assist clinical workers if some technical problems arise. Moreover, the system has to be constantly upgraded, which may demand additional costs. However, the benefits the system has while supporting clinical decision making and promoting quality outcomes clearly outweigh its limitations. Physicians have access to the full medical history of the patient; thus their clinical decisions will be of minimal risk to the patient’s health. Furthermore, medical errors are excluded from the workflow thanks to the EMR system.
There is a widespread opinion in the scientific circles that EMR plays and will continue playing an integral part of the development of evidence-based medicine and clinical practice guidelines. Besides storing patient information, EMR system includes such tools as embedded clinical decision support and helps “hospitals monitor, improve, and report data on health care quality and safety”. Evidence-based clinical practice guidelines are intended to provide practitioners with the best systematically reviewed and appraised clinical research findings, thus enabling them to deliver superb clinical care. Evidence-based practice standards refer to other physicians’ clinical decisions and are intended to make health care more consistent and systematic. Despite physicians’ worries concerning both evidenced-based medicine and EMR, they are the future of US medicine. Moreover, their successful exploitation presupposes their interconnectedness. EMR can be an efficient and useful tool while enhancing evidenced-based practical guidelines. With this purpose, EMR systems should: provide useful data to decision-makers at the point of care; offer feedback loops so physicians can measure their practice patterns against other colleagues; ensure interoperability between inpatient and outpatient facilities and among physicians; include flow diagrams and algorithms that enable physicians to exercise autonomy and clinical judgment and respond to patient preferences.
Evidence-based practice standards of care and clinical practice guidelines have long been established as the preferred option for patient treatment while EMRs have been called “the next step in the continued progress of health care” by the Centers for Medicare and Medicaid Services. Electronic documentation system records all physicians’ decisions and treatment procedures that the patient undergoes, thus creating the comprehensive basis for future researches and clinical decisions in similar cases.
Collaboration and Information
Efficient communication and collaboration are two essentials predispositions for quality patient care. In health care, collaboration is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions formulate and carry out plans for patient care. Collaboration is possible only in clinical settings marked by successful communication and teamwork. Communication between medical workers is pivotal for quality patient care. Miscommunication of any kind may e the source of misunderstanding leading to medical errors and wrong clinical decisions. Thus, miscommunication and failure to collaborate may decrease the level of health care and even become the reasons for a patient’s death. However, effective communication will certainly have positive outcomes for the entire clinic, some of which is the improvement of safety, information flow, effective interventions, greater patient satisfaction, and improvement of the overall working atmosphere for the employees.
In the clinical setting, communication and information exchange is to “occur within disciplines”, mainly between physicians and nurses, physicians and residents, nurses and nurse managers, doctors of various departments, etc. There are many barriers to effective multidisciplinary communication like hierarchy, different role perceptions, ethnic and gender differences, and some others. EMR system is going to function as intended only in the setting that promotes effective communication, collaboration, and teamwork. Although there are claims that EMR reduces the amount of live verbal communication, it is not quite so. EMRs are fulfilled and operated by medical workers from different departments. In order not to repeat the data and to make the EMR as accurate and full as possible, all clinic employees have to interact in a successful and mutually beneficial manner. Therefore, the EMR system promoted collaboration and teamwork.
Moreover, the EMR system may be an ideal tool for educating to-be physicians and nurses as they can review cases and analyze decision-making processes in different cases. However, it should happen only with the consent of patients as their safety and security are of primary importance. EMRs may serve as the valuable source of data for researches in various medical spheres as these records offer credible and valid information about diseases and the process of their treatment. Withal, the electronic system of documentation is a powerful tool in the clinical setting if it properly implemented and operated. The evaluated setting has proved to have a well-organized documentation system that helps to enhance the quality of health care. Although there are some minor shortcomings like budgetary control, the EMR system in the clinic functions as intended and may serve as the example of successful implementation of the innovative documentary approach for other health care facilities.