Refer to the summary you developed for the System Structures Overview.
Create a 12- to 15-slide Microsoft® PowerPoint® presentation, with detailed speaker notes, describing how the data is captured using your selected structure. Your presentation should include the following information:
• How does your selected structure impact the delivery of health care?
• What is the impact of future evolutions of your selected structure on the delivery of health care?
• What are the implications of privacy and security management as it relates to your selected structure?
• Identify the steps in the system development life cycle of the chosen information structure.
• What training can be provided to implement this structure?
• What maintenance components are necessary for this structure?
• How can the data be used and how can quality of the data be assured? How can you evaluate the effectiveness of the structure?
• Are there any hardware issues to consider?
Use a minimum of three peer-reviewed references, not counting the textbook, that directly support your analysis.
Systems Structures Overview
Administrative structures for clinical coordination and analysis of usage patterns
The electronic health record EHR is a computerized record of a patient's medical documentation that is used as a communication tool for coordinating treatment services between those who are involved with the patients care(Wager, 2013). The functions of an EHR is to manage health information and data, provide electronic communication between health care providers and those involved in the treatment team, provide patient support, and generate reports(Wager, 2013). Included in the electronic recordsare patient demographics, progress notes, present clinical problems, past and present medications, vital signs, past medical history, immunizations, laboratory data, and financial reports(Menachemi, 2011). The use of electronic records has taken the place of paper documentation, which was used in the past. The implementation of EHR has increased patient satisfaction, improved communication, reduced billing errors, and helps to decrease unneeded procedures and waste.
Reason for Selection/Relevance to Work Area
In selecting the information system to be discussed, the writer chose administrative structures for clinical coordination due to the relevance in the present place of employment. As a treatment provider in a Community Mental Health Agency, the use of EHR is improving the way the treatment team communicates and works together to coordinate adequate care for the patient's present needs. Prior to the use of EHR many patients reported that the coordination between their medical and mental health caregivers was poor. Patients reported that their mental health provider did not ask them about medical issues, and that their medical provider did not ask about mental health issues(Miller, 2003).The implementation of EHR is helping to reduce the communication barrier between treatment providers who are involved in the patient's present health care needs. Those patients who receive multiple services within the agency and community partners are now able to receive a greater level of care due to coordination of services with EHR.
The ability to share patient data with all treatment providers involved in the care of the patient is improving overall patient care along with reducing the number of conditions that go undiagnosed or untreated(Walker, 2008). The use of EHR helps physicians to correctly prescribe medications that are effective and beneficial to the patient's current medical state. A patient who is receiving services for substance abuse due to the use of prescription medications will not benefit from any prescribed narcotic medications. The implementation of EHR now allows the prescribing provider to see that the patient has a substance abuse problem and they will know not to prescribe the patient any medications which may make the patients present condition worse. The EHR also helps to reduce the number of patients who are seeking medication, or those who may have failed to communicate with their prescribing provider that they have a substance abuse problem and should not take narcotic medication.
Advantages to Electronic Health Records
Theadvantages to the use of EHR are significant. Clinical documentation is completed in a timely manner and there is a reduce risk of incorrect documentation in charting. With paper charting, patient documentation could get filed into the incorrect chart, and cause further clinical and billing errors. Paper charting also increased the chances of patient information being exposed to unauthorized personnel.Computerized progress notes help to reduce incorrect billing codes due to poor handwriting or data entry errors. Clinical coordination of care is increased due to accessibility of patient records among treatment providers. Patients have better outcomes due to a decreased numbers of misdiagnosed or untreated symptoms, and financial reimbursement is more efficient due to electronic documentation.
Disadvantages to Electronic Health Records
Implementing new electronic health record management systems have disadvantages related to the use of the EHR. The costs associated with the implementation of these EHR systems are significant(Menachemi, 2011). There are continual costs that will be associated with the maintenance and updates of the system. Another disadvantage is the possibility of inaccurate data entry and the accidental breech of patient confidentiality. Teaching employees who previously had little or no existence with electronic documentation may be resistant to the change in the beginning. Adequate training of staff will help to reduce data entry errors and will increase employee confidence in using the new system.
Conclusion
The implementation of electronic health records is a computerized documents management system which manages a patient's medical records. EHR's are used as a communication device within the patient's treatment team. The use of electronic records has taken the place of paper documentation, which was used in the past. The implementation of EHR has increased patient satisfaction, improved communication, reduced billing errors, and helps to decrease unneeded procedures and waste.Clinical documentation is completed in a timely manner and there is a reduce risk of incorrect documentation in charting.Computerized progress notes help to reduce incorrect billing codes due to poor handwriting or data entry errors. Clinical coordination of care is increased due to accessibility of patient records among treatment providers.
References
Menachemi, N. (2011). Benefits and drawbacks of electronic health record systems. Risk Management and Health Care Policy, 47-55.Miller, C. (2003). Barriers to Primary Medical Care Among Patients at a Community Mental Health Center. Psychiatric Services, 1158-1160.Wager, K. (2013). Health Care Information Systems. San Francisco: Jossey-Bass.Walker, J. M. (2008). EHR Safety: The Way Forward to Safe and Effective Systems. Journal of the American Medical Informatics Association, 272-277.