Introduction
The purpose of the current paper is to make the necessary recommendations for an Electronic Health Record (EHR) for the Alpha organization. The assessment is to review the essential details of the organization and make appropriate suggestions as to which EHR program is worth choosing. In addition, the paper provides the appropriate recommendations for the implementation, and testing of the selected program including training inquires.
Analysis: Organizational Overview: Organization
The Alpha Medical Center has five wards with 150 beds and five dedicated to intensive care. The clinic specializes in acute care and is classified as a Level III trauma center. The selected program is required to be adapted to each hospital department and can be securely communicated with critical patient information. The primary aim of the current investigation is to ensure that the organizational system is equipped with the necessary applications to manage all aspects of Alpha.
Analysis: Organizational Overview: Services
HCO Alpha has separate service areas that consist of outpatient surgery, women’s health, pediatrics, cardiology, and orthopedics. Additionally, the organization provides auxiliary services for family practice, internal medicine, cardiology, neurology, sports medicine, eye care, and others. All mentioned services are offered in separate clinics, which are the subsidiary of Alpha. In general, the Alpha operates thirteen service line clinics. Moreover, the organization focuses on outpatient rehabilitation and community wellness program.
Analysis: Organizational Overview: Stakeholders
The stakeholders for implementing the EHR system can be chosen from different coordinated spheres. In the area of the EHR, the stakeholders’ primary aim is to define the challenges, improve the functioning and evaluate the outcomes of the implementation from within. As a result, the stakeholders usually are chosen from the clinicians and business staff of the company. For example, allocating the billing team’s stakeholders can help gain a more detailed perspective on the financial aspect of the process. The clinicians can also be the perfect choice for stakeholders. The clinicians are able to estimate the relevancy and efficiency of the EHR implementation based on practical experience in medical service provision.
Design: Applications: Health Informatics
The most vital health informatics application which should be present in the EHR system is the public health surveillance inquiries. It allows providing integrated care for patients, allowing them to learn in more detail about their health condition and assigned treatment. Moreover, the secure data allocation of the patient health conditions can be efficiently redirected to any clinician in charge of current therapy (Giardina et al., 2019). Such an application of health informatics minimizes the time spent on diagnosing and decreases the risks of medication error occurrence.
Design: Applications: Requirements
An effective EHR system must meet many requirements, including ASTM, the international organization that produces them. The organization’s remit includes standards for healthcare data management, confidentiality, and documentation. CEHRT certification requires meeting functionality and interoperability criteria. Components such as ensuring that an electronic prescription system or order entry into a registry is fully functional are part of the certification process. Information exchange is used to improve the quality of the medical system.
Design: Applications: Scope
Generally, all the applications of the EHR perform the functions of managing patient care alerts, providing clinical guidelines, and alleviating documentation keeping. The first one is the Registration-Admission, Discharge, Transfer, which is responsible for insurance and patient demographic information. In addition, this application can include the Major Patient Index (MPI) (Block et al., 2019). The second application is the ordering and receipt system ensuring rapid coordination between departments. The third is the patient monitoring application focusing on collecting the critical for current treatment metrics of particular patients (Block et al., 2019). The fourth application is the Document Management System (DMS), helping to relocate the patient’s information from paper carriers to electronic ones. The fifth is ensuring the messaging system and provider-patient portals among the clinicians, patients, and nurses.
Design: Applications: Data
The secondary data required for the successful implementation of the EHR is the complete history of the patient’s health. Such data is usually accommodated on the paper carriers. That is why mentioned above applications are vital in data collection. Another type of secondary data is the prescription history of the patient. The representation of such data in EHR is critical because it can decrease information-related medication errors, which increases the general quality of the medical services provided.
Design: Applications: Health Information Exchange
Mentioned applications increase information transmission quality, speed, safety and costs. In other words, the health information exchange (HIE) can be achieved more easily by using the inquires of health informatics. The implementation of these aspects will help to avoid the paper folders and transfer all the vital patient information into the electronic format quickly. The clinicians and patients will gain access to the medical history and current treatment, ensuring enhanced communication and more qualitative outcomes.
Design: Applications: Security
Data protection measures must include access controls, audit logs, and antivirus software. Combinations of security and encryption measures are necessary to ensure the protection of patients’ personal information fully. If the system contains two-level authentication, passwords, and other measures, there is a high probability that the program will be secured on time in the event of a threat. Audit logs are essential because they provide a way to track changes in information within the system so that everyone who has access to the relevant records can be informed. An anti-virus system is a strong shield against viruses and other malware that can potentially damage the system. In addition, encryption software should ensure the entire operation of each component.
Design: Applications: Disaster and Recovery Planning
In equipment damage or a natural disaster, organization needs to have a competently designed plan in place. It is essential to have recovery procedures in case of an emergency or fire that will help repair the damage on time. A backup copy of all available files is mandatory to keep outside the organization for security purposes. In case of a breach or loss of information, such copies will allow the system to be restored to working order quickly. Duplicate copies of the existing copy, dispersed in different locations, assure that the company has multiple versions of the original data.
Design: Applications: Computer-Assisted Coding
International Statistical Classification of Diseases and Related Health Problems includes the vast number of specialized coding implications which can be suitable for Alpha’s offered services. This internationally standardized medical classification can be used as the basis for the coding and billing procedures. In practice, computer Assisted Coding (CAC) analyzes the information it receives from dictation and typing and translates it into ICD-10-CM, ICD-10-PCS, and CPT codes.
Design: Applications: Capabilities
Once CAC has translated the typed and dictated information into the medical record, the system advises on the code to be used. The staff member in charge of medical coding reviews the selected code and either approves or rejects it. This process dramatically saves time on coding information, which increases the efficiency of the entire system. In other words, the general productivity of the medical services provider can be significantly increased. Moreover, it improves data transparency by defining the codes as a part of the treatment process.
Design: EHR Selection: EHR
The system which can be relevant for Alpha is the EpicCare Inpatient and Ambulatory Base (Epic). The program is ONC certified meeting several clinical quality metrics (Newman, 2020). The federal government approves the system as being one of the most popular certified EHR programs. The system is easy to use and customize according to the healthcare facility’s needs. The program is best suits for the company because it allows Alpha to connect with other medical facilities. Moreover, the status of the organization will also be increased due to the usage of the certified system.
Design: EHR Selection: CMS Regulations
There are several regulations that the EpicCare EHR system complies with; these are prescriptions and health information exchanges (HIS). For example, electronic prescriptions, through which Epic EHR interacts with pharmacies, given the option for the provider to send prescriptions to the patient’s address.
Design: EHR Selection: Type of EHR
The chosen type of EHR is the physician-hosted system. This system allows for allocating, managing, and connecting valuable information from varied subsidiary clinics. As was mentioned earlier, Alpha has many small clinics which should also be included in the process of EHR implementation. Therefore, unique organizational services should be established to manage such vast data. Despite being more expensive due to the expenditures on the software, this type of EHR is more suitable for Alpha due to the company’s size and operational needs.
Design: EHR Selection: Patient-Centered Technology
The Epic EHR system supports primarily patient-centered technology, as expressed through patient-provider portals. This option provides a secure line of communication between the provider and the patient. The patient can make appointments with the provider, refill medications, check test results, and pay for services. According to research, online access to medical records allows patients to get more information about prevention, problems, and health promotion. Round-the-clock access to the portal allows patients to become more proactive about their health.
Design: EHR Selection: Peripherals
Being cloud-based allows an organization not to have their servers, but it can help to have at least one in an emergency. Alpha needs to purchase the necessary number of laptops, tablets, keyboards, and other things that streamline the process. It is essential to determine if the hospital will use mobile stations or telemedicine to understand potential purchases. The above reasons further validate EpicCare EHR as the right system for transitioning to digital media. In addition to the advantages mentioned above, the system is easy to use and configure, and its functional adaptability is high.
Implementation: Data Entry
Typing as the primary method of data entry into the EHR is chosen for the Alpha. The primary reason for such a decision is that this approach minimizes the risks of information-related errors. Moreover, the computer checks the information based on the applied qualities, which allows for avoiding many mistakes. The system of automatic selection can also be helpful in alleviating the work of clinicians and nurses. The form or template which is used affects the ways how data is perceived and captured. For example, the laconic forms using the keywords not only help clinicians orient more quickly in the data but also allows the computer to process the information more effeminately.
Implementation: Testing
In order to ensure the functionality of the EHR system, real-time testing can be implemented. It requires the allocation of the EHR specialists such as vendors (Bouhaddou, 2019). Such an approach can help to correct the identified errors and provide more efficient testing and retesting of the system work, which will help to prevent future bugs.
Implementation: Education and Training
Once the data is being entered into the system correctly, the next equally important part is employee training and education. If the employee is adequately trained on the system, it is more efficient to adapt the new system to the organization’s needs. Interactive instruction is an essential part of practical training that contributes to adapting the system into a working structure quickly. Facility staff takes classes separately from coding staff. Also, at the time of the training, it is essential to consider the interests of the staff so that they do not come in when they have the day off. It is necessary to consider that everyone has a different degree of learning. Users must stay updated with news and changes to assess their impact on the organization.
Conclusion
So far, the transition from paper records to EHRs has been a huge hurdle to overcome to provide our patients with proper care and make it easier for workers to do their jobs. By accessing the system, the patient becomes more involved in treatment and communication with facility staff. The goal of any medical organization is to provide the best possible service. An EHR system will allow an organization such as Alpha to gain the necessary level of understanding between its members and patients.
The implementation of EHR can increase the general efficiency of Alpha’s operations. The change to the electronic records can help clinicians and nurses to avoid the occurrence of medication errors. The implementation of EHR should be supported by medical informatics technologies, efficient training, and software provision. Only the combination of the mentioned aspects can increase the quality of provided medical services, helping clinicians focus on the documentation work and the diagnosis.
References
Bouhaddou, O., Othmani, M. B., Parks, R., Serhier, Z., & Wigand, R. T. (2019). Electronic health records implementation in Morocco: Challenges of silo efforts and recommendations for improvements. International Journal of Medical Informatics, 129(2), 430-437. Web.
Block, S., Lamas, D., Hammes, B., Hanson, L. C., Henrich, N., Meier, D. E., & Panariello, N. (2018). Advance care planning documentation in electronic health records: Current challenges and recommendations for change. Journal of Palliative Medicine, 21(4), 522-528. Web.
Giardina, T. D., Murphy, D. R., Satterly, T., Singh, H., & Sittig, D. F. (2019). Practicing clinicians’ recommendations to reduce burden from the electronic health record inbox: a mixed-methods study. Journal of General Internal Medicine, 34(9), 1825-1832. Web.
Newman, D. (2020). Epic systems modules & software: Hyperspace, Healthy Planet, ClinDoc. Healthcare IT Skills. Web.