NR 361 Experiences with Healthcare Information Systems

NR 361 Experiences with Healthcare Information Systems

NR 361 Experiences with Healthcare Information Systems

Most of my nursing experiences with healthcare information systems are from nursing school as a nursing student. I had clinical rotations at nursing home, short/Long-term rehab center, and hospitals. In nursing home setting, they use both paper and computer charting. Paper charting is used for daily activities such as vital signs, In&out and daily schedule. Computer charting is used for administration, health history, meds record, doctor’s order, and notes. In rehab center, they used computer basis charting all the time, but they also provided a binder with paper sheets/forms for each patient at nurse station. I feel kind of like this style especially when computer is not enough for everybody to use, or computer doesn’t work for some reason. The information is actually straight forward for nursing student who want to know the whole picture of patient and not familiar their electrical information system. In hospital setting, I was able to have experiences with EPIC system. As a student, we have access to the system with our own username and password, but we are not allowed to do documentation unless it approved by our supervisor. I thought it is simple and straight forward to use after training. “Due to the applied nature of HIT, provision of skilled training plays a critical role in adoption and maximized use of HIT. Nurses, Physicians, allied health care professional, and healthcare support staff must become skilled in both the use of computer technology and the use of health-information system; effective training is a key piece of this process.” (Hebda, Hunter, & Czar, 2019 p. 219.)

I am currently in orientation at a long term rehab center in Connecticut where I had clinical rotation as a nursing student last year. The transition is a lot easier for me since I practiced there for a whole semester, and they basically had no big change of the information system. I believe my previous nursing experience in the facility as a nursing student build a very good foundation for successful transition. They use Point Click Care system for data entry including health history, assessment, treatment, notes such as fall accident, fracture, ulcers, etc. They also have paper sheet for charting since they just have two computers available at nurse station. At the end of the shift, the floor supervisor will check everything and enter the data into computer selectively.

Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.

Week 2 Discussion Post:

My experience with different healthcare information systems is limited because I have only worked at one hospital. When I started at this hospital, the physicians were still hand-writing orders and progress notes. They had already integrated a basic electronic charting system called Meditech, for the nurses to chart and the secretaries to transcribe the hand-written documentation from the physicians. In 2013, my hospital converted to all electronic medical records and overall it was an easy transition. As a 19-year-old, computers and new applications did not scare me. But I believe the sudden implementation of this system forced some of the older physicians and nurses out of the hospital setting. My experience with healthcare information systems has been positive. According to our textbook, Electronic Health Records have the ability to “add decision support and flag potentially dangerous drug interactions, verify medications, and reduce the needs for risky tests and procedures” (Hebda, Hunter, & Czar, 2019, p. 119). One example of how this feature has helped me is when I have patients who are receiving IV Furosemide, the system will alert me if the patient’s last Potassium level was low and it has not been re-drawn recently. The government was a driving force in the implementation of electronic healthcare information systems. In 2009 President Barack Obama signed a piece of legislation called the Health Information Technology for Economic and Clinical Health (HITECH) Act. This act provided more than $35 billion to hospitals and clinics to encourage the use of Electronic Health Records (Reisman, 2017).

 

References

Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.

Reisman M. (2017). EHRs: The Challenge of Making Electronic Data Usable and Interoperable. P & T : a peer-reviewed journal for formulary management42(9), 572–575.

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Share your experiences with healthcare information systems, past or present. Has it been an easy transition or difficult? Why do you believe your experience has been positive or negative? If you are currently not working in a healthcare setting, how has the medical record exposure in nursing school impacted your current knowledge?

I have worked in a variety of healthcare settings throughout my career before I became a nurse. You could even

NR 361 Experiences with Healthcare Information Systems
NR 361 Experiences with Healthcare Information Systems

consider lifeguarding part of healthcare because I was CPR certified, although I didn’t ever have to document anything or save anyone. I worked in a doctor’s office for a few years while I was starting school. This office was private practice, so they didn’t have an electronic documenting system. All the charts were paper, and they were very heavy! If I took a call from a patient, I had to find their chart in the files and hand write what they needed and give it to the doctor for him to reply. I learned spelling and medical terms very quickly! Although this system mostly worked for their needs, I sometimes found other patients results in others charts. Every result was faxed to us and sorted and filed by hand. Therefore, a lot of mistakes were made and there wasn’t a great way to monitor that the correct papers were getting into the correct charts. If a specific result was lost, there was really no way to find out where it went, we would just have to have another copy faxed. Thankfully while I was there nothing catastrophic happened, but with no safeguards in place, it’s really only a matter of time. In a study comparing electronic documentation verses conventional (paper) charting, this found that the electronic documenting showed more diagnoses for each patient, less false or redundant ICD codes, and less time spent on documenting (Stengel, Bauwens, Martin, Kopfer, & Ekkernkamp, 2004). Improper or false ICD billing codes can get you in a lot of trouble, even if you’re not doing in on purpose. Medicare fraud is highly monitored and can negatively affect a physician’s medical license. Not to mention the potential repercussions for the patient receiving wrong information and potentially having to pay more money unnecessarily.

I found the transition from that old paper system to an electronic system to be very smooth. I often felt like I lacked detail in some instances and I know how important documenting is. But the amount of time I spent hand writing requests in the chart took away from the amount of detail I could put into it. I was already spending extra time after the office closed to call back the patients who had called that day, I didn’t have any extra time to write more. I can type a lot faster than I can write, so an electronic system would have really helped streamline this office. I understand how expensive it can be to convert, so I realize why they never changed over. I used Epic documenting now and I could not imagine what it would be like to try and document a hospital patient with a pencil and paper. I already spend a lot of time charting, I feel like I would never get the amount of detail necessary while trying to hand write all my documentation.

Stengel, D., Bauwens, K., Martin, W., Kopfer, T., & Ekkernkamp, A. (2004). Comparison of Handheld Computer-Assisted and Conventional Paper Chart Documentation of Medical Records: A Randomized, Controlled Trial. Journal of Bone and Joint Surgery, 86(3), 553-560.