Computerized Clinical Documentation System

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Computerized Clinical Documentation System

Tele-home nursing seems to be beneficial for those patients who do not have an opportunity to get to the hospital, but I, for one, would not consider a tele-home health nurse as my future career. Though the technology use has become extremely beneficial for nursing lately and offered numerous alternative ways of treating the patients, I still keep to an idea that only personal contact may guarantee correct diagnosis.

For instance, in Evan Rosens article the nurse is treating her patient via video from cough and panic attack related to it (Rosen, 1997). Perhaps, widespread illnesses which do not need examining the patient thoroughly may be treated by means of video examination. However, the complicated ones demand more thorough examination. Of course, there is no crucial need in touching the patient when he/she has a cough, but when the nurse deals with a stomach ache, the palpation of stomach is extremely important. Besides, if the doctor needs to examine skin redness or the like symptoms (rash, for instance), the quality of the video may mislead him/her. The same goes for heart beating and breath measuring; the connection may not be well enough to hear everything, which may lead to serious consequences afterwards.

Lastly, video connection may be unreliable; this may result in the nurses inability to finish the appointment. Therefore, there are three main reasons why I would not like to be a tele-home health nurse. First of all, I think that personal contact is needed to diagnose a patient. Secondly, tele-examination may be misleading. And thirdly, the examination may be impossible due to instability of Internet connection. This all makes tele-nursing not suitable for me.

The article The Second Time Around deals with the Pediatric Partners introducing an on-demand PM and billing service to cope with the process breakdowns which the organization used to experience. The author mentions that the try to introduce an electronic medical record (EMR) was already made in 2005 and it failed. Now, however a new solution has been worked out. This solution could allow the organization to deliver better patient care along with achieving consistent financial results (Mohr, 2008, p. 22).

In order to install EMR properly, a selection process was initiated. During this process staff and administrators have been gathering to discuss their concerns about their current PM system, as well as some cost-effective issues. After that, they finally selected athenaClinicals as a new EMR system. After certain training carried out, the administration got convinced that the program was beneficial because clinical workflow had significantly improved.

Moreover, the system helped to manage numerous activities in the organization: We leveraged the clinical document management service to integrate all the moving parts of our practices scheduling and billing, automated coding, and clinical task management into a single clinical workflow system (Mohr, 2008, p. 23). The system implementation became especially effective for the organizations smaller locations and helped them successfully carry out all these activities despite a rather low staff amount.

However, this system still has proven to have certain disadvantages. For instance, not all the clinical papers were managed properly and the number of calls into clinical practices has been significantly limited due to the systems controlling the connectivity to the clinical laboratories. Despite this, EMR system has been mostly beneficial for the organization because it facilitated and improved a number of processes which the staff was going trough daily.

Information technology has spread over the world and changed a number of processes in which people participate. Health care was among those spheres of human activities which were obliged to use information technologies to improve the quality of services it offers to the population.

Informatics within the healthcare sphere may be defined as all aspects of understanding and promoting the effective organization, analysis, management, and use of information (Carty & An, 2007, p. 26). Since spheres within healthcare are numerous, a more accurate definition for informatics in healthcare had to be worked out. Taking into account all the complexity of healthcare sphere, healthcare informatics can be defined as facilitating the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles, and settings (Carty & An, 2007, p. 27).

Data which a person obtains are transformed into knowledge which is further applied to ideas a person has or procedures in which he/she participates (Carty & An, 2007, p. 27). The correlation of these three concepts is extremely important for a persons decision-making process.

Health information technologies have a profound effect on the work of healthcare delivery systems. This is why perceiving the use of HIT as an organizational change and planning to implement it properly will help to make this change effective for any healthcare organization.

Health Information Technology and Electronic Health Records offer a number of benefits to their users. The most evident are cost benefits, though reduction of medication errors (especially with dosage) and more accurate prescriptions should not be underestimated.

The strategies for implementing Health Information Technology and Electronic Health Records focus on three main objectives. The first one is getting funding due to these technologies high cost of purchase and maintenance. The second one is training of the personnel to use these technologies. And the final one is the technical support which will ensure proper functioning of the technologies.

NextGen has more advantages than disadvantages. Its biggest benefit is that, apart from selling EHR, it cooperates with small and group practices, as well as health systems and hospitals; moreover it updates itself with real-time shared information (Boehm-Davis, 2008, p. 3). Its biggest disadvantage at this is that it does not maintain data integrity. This, however, depends on the needs of the groups and their ability to ensure security of the data.

GE, in its turn, provides different tools which help to manage and improve patient care and simplify clinical practice; it automates documentation and allows easily managing it. One of its disadvantages, however, is that it eliminates what it considers to be inconsistencies or redundant data which sometimes need to be preserved. Finally, the biggest advantage of EHS Care Revolution is that it offers EMR products and integrated Practice Management. However, its disadvantage is that, in case with its ASP product, the disaster recovery location is only in England.

Studying these systems and the issues related to them, I have learned that training and practicing is the most important to become a professional. Another thing which I have learned is that working with the abovementioned systems takes much time and efforts. The staff needs to be trained in every aspect of their work. For example, in primary care, an expert user has to be a provider and deal with clinical support, front end and billing. Besides, during the training, the staff needs to have access to all the appropriate resources, as well as obtain ongoing education on specific functionality in future.

An organization that wishes to implement the systems mentioned above should follow several necessary steps. First of all, goals should be firmly set before any EHC is implemented. Secondly, Timeline for implementation and training should be outlined with necessary resources being evaluated and spared out. Finally, expectations and roles before, during, and after implementation should be identified and then strictly observed. This will make the implementation of EHS successful.

Reference List

Boehm-Davis, D.A. (2008). Assessing the Research and Development Plan for the Next Generation Air Transportation System: Summary of a Workshop. Washington: National Academies Press.

Rosen, E. (1997). Twenty minutes in the life of a tele-home health nurse. Telemedicine Today, 5(6): 12.

Mohr, T. (2008). The second time around: a California practice learns lessons from their first EMR and integrates their PM with a new, on-demand EMR for an improved bottom line and clinical workflow. Health Management Technology, pp. 22-24.

Carty, B. & An, J. Y. (2007). Health care informatics: A vital discipline in health information technology. Global Social Security Today, Fall 2007, pp. 26-33.

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