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Case study clinical decision support system
Case study clinical decision support system
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CDS Systems, EBP and Clinical Guidelines:
Similar to Global Positioning Systems (GPS) provide drivers with directions, detours, alternative routes, and alerts, Clinical Decision Support (CDS) systems provide health care professionals with guidance for important decisions associated with patient care. These systems have many capabilities including synthesizing patient information, suggesting diagnostic tests, providing alerts for life-threatening situations, recommending treatment options, and providing relevant evidence and best practices. Nonetheless, just as GPSs, CDS systems are not usually perfect as evident in the ongoing evolution of their design specifications and functionalities. Some of the major issues that are still evolving for CDS systems include alert fatigue and integration of evidence-based practice (EBP) resources and clinical guidelines. One of the major areas that can benefit from the adoption and integration of clinical decision support systems is community health nursing. These systems can be used together with evidence-based medicine to help improve the quality of health and patient care in community health nursing.
Integration of CDS Systems in Community Health Nursing:
Generally, the development and adoption of Clinical Decision Support (CDS) systems is based on the necessity and essence of technical standards in enhancing healthcare. However, the various health IT tools must comply with some data interchange standards in order to enhance access to clinical records, lessen clinical errors and risks to patient safety, and promote innovation in “individual-based” care (Hammond, Jaffe & Kush, 2009, p.44). The need for compliance with standards is fueled by their role in enabling aggregation of informa...
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...benefits of this type of clinical decision support system include easy access to information and patient records, provision of timely support throughout the care process, reduced costs, enhanced efficiency, and reduced patient inconvenience. However the disadvantages include potential difficulties in interpreting information, difficulties in handling the huge amount of nursing literature, and probability of additional demands to care process.
In conclusion, clinical decision support systems provide a mechanism for improving the quality of care services when integrated with evidence-based practice and clinical guidelines. These systems would particularly improve health care quality when combined with evidence-based medicine. This process may also include the use of databases and condition-specific clinical guidelines to improve their effectiveness and efficiency.
Advantages: Fast and simple – Easy to understand – With different EHR programs (EPIC or Powerhcart) all the standardized terminology are the same – Not only nursing understand the terms but other healthcare providers will also – There should be no assumption what the terms mean because it’s a universal terms in all EHR.
The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
Introduction “Health informatics is the science that underlies the academic investigation and practical application of computing and communications technology to healthcare, health education and biomedical research” (UofV, 2012). This broad area of inquiry incorporates the design and optimization of information systems that support clinical practice, public health and research; understanding and optimizing the way in which biomedical data and information systems are used for decision-making; and using communications and computing technology to better educate healthcare providers, researchers and consumers. Although there are many benefits of bringing in electronic health systems there are glaring issues that associate with these systems. The
A few added helpful things it does is: installs quickly, lets patients do more, and is more profitable. Epic has been named the number one overall best software in 2013. It continues to get great ratings about how quick they are. Epic system also is not only helpful to the employees it is also very useful for the patients. Like I mentioned in a prior statement, Epic system allows patient to be able to log in and see their history of health. This helps the patient because they can keep track of all of their medical history, as well as print off the information they may need instead of going through the actual facility. According to a Nurse colleague of mine, I had interviewed her about this product. She says “it is a great system and very easy to work with.” She claimed it helps out a lot to have the e-learning class to jump start on the system when you’re a new employee. At her current location, all the employees love the system, and love to be able to learn hands on from day one of
...f clinical information systems in health care quality improvement. The Health Care Manager. 25(3): 206-212.
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
One of many nationwide initiatives to help reduce the occurrence of unnecessary medical errors and adverse events is the use of the integrated Clinical Decision Support System (CDSS). A CDSS is a system that provides the right information to the right person in a right format through a right channel at the right time of workflow to facilitate better decision-making by clinicians, reduce errors, and also to prevent adverse events (AHRQ, 2008). This proposal is a case based CDSS system that provides point of care clinical decision support, ensures five rights of medication administration (right person, right drug, right dose, right time and right route), and is designed to prevent or reduce the occurrence errors and adverse events at Perpetual Order of Saints Hospital (POSH).
Similarly, Murphy (2014) has discussed some features of CDSS that will influence its success and make it more effective. Computer based generation of decision support - Automatic provision of decision support as part of clinical workflow - Provision at time and location of decision making. Provision of a recommendation, not just an assessment. Provision of decision support results to both clinicians and patient systems providing advice for patients in addition to practitioners. On the other hand, Sittig et al (2008) have discussed the grand challenges of CDS and placed them into the following three large categories: A) Improve the effectiveness of CDS interventions: 1) Improving the human-computer interface 2)
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
This means the patients’ healthcare information is scattered among various resources. This makes it difficult for physicians to develop an informed decision about the patient. Our interoperability services allow physicians and other registered healthcare services to access the patient data aggregated from different software applications, and systems. This helps them minimize diagnose errors, and avoid confusions regarding medicines. Also, patients can access their medical records and track their own
Also, these studies question those who are effected; in this case, those who are most effected, is everyone. Doctors and nurses spend the most time working within these systems, but the information that is put into these systems effects every individual in America, because it is their information. Because nurses are often considered “both coordinators and providers of patient care” and they “attend to the whole patient,” their opinion is highly regarded (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh, 2007, p. 210). It is clear that the use of these new systems is much debated, and many people have their own, individualized opinion. This information suggests that when there is a problem in the medical field, those who address it attempt to gather opinions from everyone who is involved before proceeding. It has been proven by multiple studies that this system of record keeping does in fact have potential to significantly improve patient health through efficiency, and it is because of this that the majority of hospitals have already completed, or begun the transfer from paperless to electronic (Otieno, Toyama, Asonuma, Kanai-Pak, & Naitoh,
Healthcare organizations are commonly faced with data communication challenges that can impact clinical workflow and patient care. Several healthcare organizations have found significant benefits with the implementation
There are various clinical information systems and these are some: -Clinical Decision Support: clinical decision support will provide knowledge and information for clinicians, patients, nurses and for the whole staff of the healthcare facility. Clinical Decision Support will provide tools for providers so they can use, apply, and display for easier, accurate, time and correct decision making, avoidance of errors, cost benefit for both patients and clinicians and increases the care for patients during and after the clinical workflow. Tools examples are computerized alerts, reminders, clinical guidelines, documentation templets, and reference information. -Electronic Medical Records (EMR): here providers will have both standard medical data and
Data interchange standards are types of standards in healthcare that seeks to standardize the messaging, communication and integration of applications and systems not only nationwide but internationally. As mentioned in the text there are several types of data interchange standards, but there are four main ones that have been “recognized as important.” These four standards are Health Level Seven (HL7) standards, Digital Imaging and Communication in Medicine (DICOM), National Council for Prescription Drug Programs (NCPDP) and ANSI ASC X12N standards. (Wagner, Glaser, Lee, 2013)
Using a system to access health information can have a positive effect on the quality and delivery of nursing care and patient outcomes. Health information systems can dramatically improve the ability of providers to diagnose diseases. When providers have reliable access to patient’s health information, they can see a clear picture which can help providers in diagnosing patient medical issues quicker. A health information system can reduce errors which can positively affect patient outcomes. The HIS can keep records of patient medications and allergies and will automatically alert clinicians when if there are any potential issues. The HIS is a crucial component in the delivery of nursing care. Documentation is an integral part of nursing