ELECTRONIC HEALTH RECORDS ISSUES & CHALLENGES

IN A GOVERNMENT INSTITUTION

MARY GRACE A. VILLAREAL, RN

“COMING TOGETHER IS A BEGINNING. KEEPING TOGETHER IS PROGRESS. WORKING TOGETHER IS SUCCESS.” -Henry Ford

Photo Credit: http://www.bayhewitt.com

TIME REQUIRED TO ENTER DATA VS. MORE TIME WITH PATIENTSUpon introduction of computerisation to the clinical area, bulk of work is coursed through the nursing staff. Encoding of request (laboratory, prescription, & charging of procedures and supplies)

Medication Request

Photo Credit: MedlinePlus.gov

Gives prescription to

Nursing Staff for Encoding

SOLUTION:• Give physicians access to directly encode prescriptions. • Pharmacy staff can render medications issued. • Nursing staff will charge medications given per patient.

Avoidance of duplicate

task=

Efficient workflow;

Quality patient care

Photo Credit: http://www.dementia.org

LACK OF CUSTOMISATION VS. TIME TO LEARN THE SYSTEM

The system provided by the institution is geared towards a paperless clinical area. Since it was provided pre-built the users were left to adjust & adopt to the system, without taking into consideration the users’ needs and requirements.

Image Credit: http://macrovations.com

SOLUTION:• Work with the end-user in design and observe their work

flow. • Provide a system that will meet the users’ special needs or

requirements. • Give ample time to train staff, provide feedback and support. • Give periodic follow up regarding system use, and audit

works done.

Customized System

Training Ease; System

Adaption

Staff Participation

CLINICAL DATA ENTRY ERRORS AND MULTIPLE RECORDS

The point and click and drop-down menu capabilities of most EMR systems foster the propagation of erroneous data. Unless a provider takes the t ime to aud i t the electronic record on each visit, inaccurate information can be placed in a record and continued forward.

-Kevin R. Campbell, MD

SOLUTION:• Assign a “unique number assigned to each patient within a

hospital that distinguishes the patient and his or her health record from all others” (Johns, 2002)

• Consolidate duplicate records, and migrate out-patient and in-patient data.

• Educate and train users in health record documentation and prepare them for EHR implementation.

• Provide data standards within the institution, if possible, within the industry.

http://www.shorelinerecordsmanagement.com

Image Credit: http://allthingslearning.files.wordpress.com

CONCLUSION:

In every system, there will always be room for improvement and evolution. Resistance will always be met, but by finding champions who will advance the program change can be shown as a more tangible process. Involving the users’ and showing them the possible benefits will provide the long term ideals of Electronic Health Record use. Data quality is significant, “garbage in = garbage out”, by training, standard implementation and audit it can be translated into valuable information. Privacy and security being the constant guide to building great EHR systems.