Assessment of Nursing Information Requirements Assignment A collection of data, which are interpreted, analyzed, and translated into meaningful information is important for decision-making (Steege, 2017). Many healthcare professionals including nurses, physicians, nurse practitioners, and others relies on patient health data that has been translated into information to support their clinical decision making. These healthcare professionals can provide qualitative care, prevent errors, and improve work efficiency by utilizing the information (HealthIT.gov, n.d.). Hence, it is important to determine what information are needed by the users. I interviewed a nurse practitioner (NP) to understand information needs in her current practice area.
Introduction
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According to HealthIT.gov (n.d.), the electronic HIE can provide vital patient information in timely manner and promote better communication among the providers. Eventually, HIE helps providers to see a bigger picture of the patient and lead to better inform decision making at the point of care. In addition, the proper utilization of electronic HIE by providers can lead to avoidance of readmissions and medication errors, improvement in diagnoses, and reduction in duplicate testing (HealthIT.gov, n.d.). It is possible to exchange data electronically if the EHR is interoperable. Nelson and Stagger (2014, p. 399) defined interoperability as “the ability of health information systems to work together within and across organizational boundaries to advance the effective delivery of healthcare for individuals and communities by sharing data between …show more content…
In the absence of patient health information data within or across the healthcare system, a provision of safe, quality, and reliable care is breached. Although there has been an adoption of EHR widely by several organization to improve care, there is still a lack of interoperability. Several organization including this clinic where the No works is facing the challenge of lack of interoperability. Even though the initiative to achieve interoperability is challenging, it is still attainable and persistent joint effort will be required to achieve this
• Provides a basic level of interoperability among electronic health records (EHRs) maintained by individual physicians and organizations
Hebda, T. & Czar, P. (2013). Handbook of Informatics for Nurses & Healthcare Professionals. (5th Edition). Upper Saddle River. : N.J: Pearson Education
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an incentive, the government began issuing payments to those providers who “meaningfully use certified electronic health record (EHR) technology.” (hhs.gov) There are three stages that providers must progress through in order to receive theses financial incentives. Stage one is the initial stage and is met with the creation and implementation of the HER in the business. Stage two “increases health information exchange between providers.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) Stage three will be the continuation and expansion of the “meaningful use objectives.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) The hospital, where I work, initiated the HER mandate many years ago. In this paper, I will discuss the progression and the challenges that my hospital encountered while implementing the EHR mandate.
Vincent nurses, provides a framework for professional nursing practice guided this research. As the business of healthcare is about taking care of people, the model starts with the patient, and their family, as the central focus. Surrounding the patient, are the concepts of mind, body and spirit, which cause us to think holistically regarding the care provided. Finally, the core values/ faith based practices, guide us in managing our patients in a way that is consist with our culture/ values, supportive of our professional growth, encourages the use of best practices, that result in better outcomes, and makes us productive in a way the encourages giving back outside the hospital as well (Stone, 2011).
Electronic Health Record (EHR) is a digital collection of patient health information instead of paper chart that captures data at the point of collection, supports clinical decision-making and integrates data from multiple sources in any care delivery settings. The health record includes patient’s demographics, progress notes, past medical history, vital signs, medications, immunizations, laboratory data and radiology reports. National Alliance for the Health Information Technology defines EHR as, “ an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more
K.W. often needs to communicate his knowledge both to the patient and in the patient’s chart. This competency relates to assessing for the best available evidence to influence healthcare outcomes (National Organization of Nurse Practitioner Faculties, 2012).
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
What is HIE? What does HIE stand for? HIE stands for Health Information Exchange. Health information exchange is where healthcare information is moving across the different organization that is between a community or hospital system. HIE lets doctors, nurses, pharmacists, and other providers and patients access health information to share patient information. HIE also improve safety, and the terrible cost of patient care. Honestly, HIE along with HIT is basically still being defined in the United States, meaning they are still trying to find out what purposes is it serving in the United States. In some ways HIE is still struggling with many things that are included in federal and state grants. However, with all this HIE still provide a great
The EHR is a computerized health record that will take place of the paper chart. The health care information will be available to all health care providers at anytime, anywhere. The record will contain medical history, diagnosis, medications, immunization, allergies, diagnostics and lab results; from past doctors, emergency department visits, school, pharmacies, and out patient laboratories and facilities (Department of health and human services, 2014). Health care providers will be able to access evidence-based tools to aid in decision-making. EHR will also streamline workflow, and support changes in payer requirements and consumer expectations. In 2004, “the HHS secretary, Tommy Thompson appointed David Brailer as the national health information coordinator to provide: leadership for the development and nationwide implementation of a interoperable HIT infrastructure, with the goal of establishing electronic health records...
The transitioning nurse must be able to communicate clearly and effectively. Often times nurses working in the community are alone where there is no other health team member present, therefore complete communication is essential. Transitioning nursing must possess knowledge of computer technology. The use of computer technology allows the nurse to communicate with other healthcare providers, facilitate care and manage complex healthcare needs (Bates et al., 2016, p.342). Furthermore, nurses transitioning from an acute care setting must be able to adaptable to any given situation or community. For example, supplies and equipment found in a hospital setting can be different than the one found in a client’s home. They must take the opportunity to gather information on how to utilize the supplies or equipment that may be unfamiliar. Finally, transitioning nurses must be knowledgeable about community resources. Knowledge of community resources can provide the opportunity to access and share information and help to improve the client’s quality of life (Bates et al., 2016, p.
Physicians, administrators, staff, and patients who are affiliated within the healthcare organization should understand the importance of interoperability by coming together to ease ...
There are obvious benefits to the technology such as quick access to patient information, efficient and faster billing, and lower storage costs. In addition, there are huge advantages to linking laboratory, radiology, and pharmacy information to the larger EHR. According to Murphy (2011), linking this data is very patient-centric as it lessens the likelihood of repeating tests, thus better care decisions happen when current data is available. However, there are cons to the technology that are hampering its full acceptance. In the digital age, the public is becoming aware of how pervasive computers are to our everyday lives. Computers run our cars; manage our financial matters, and numerous other daily functions. In addition, computers and electronic information allow medical devices to function and more often than not, track our medical footprints. When the shift to EHR was nearly mandated, the one consideration not taken into account is the public’s mistrust of how the healthcare industry uses this information. Certainly, those in the healthcare industry want to keep their patients healthy, heal them when illness develops, and develop better ways of treating disease; however, the medical industry, like all businesses, are motivated by profit. According to Blankenhorn (2010), medical records, from pharmacy records
The process of implementing an EHR occurs over a number of years. An electronic record of health-related information on individuals conforming to interoperability standards can be created, managed and consulted with the authorized health professionals (Wager et al., 2009). This information technology system electronically gathers and stores patient data, and supplies that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system functions as a decision support tool to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lower the medical costs. Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely to provide better preventive care than were healthcare professionals who did not.
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
1.The characteristics that intrigued me of the nursing practice was as a patient at the Danbury Medical Center. As a patient, the nurses gave me the most delightful patient care ever received. They took their time to make sure my care was an urgency. When my pain had increased the nurses were there by my side. They had taken the time to make sure the proper dose of medicine was given to me at the correct time. Even though my current status was lying in bed with a fractured femur. They took the time to make sure my needs were met. I had never expected that going to the hospital from flying off a cliff on my skateboard would direct me in my future dream job. The nurses showed me what patient care really and truly was. Patient care is putting others in front of your own needs. Being a great nurse is showing your patient that there is hope. Patient care is not only making sure your patient is satisfied but making sure their family and loved ones are cared for as well.