Question

 

Choose a health care organization or provider with which you are familiar, and describe its patient information capture process. Does this process support operational effectiveness, satisfy compliance requirements, and promote quality patient care? Explain.

Answer 1

Short of information technology to permit the combination of information across surroundings and time, the practice of indication founded medicine converts approximately impossible. Information combination can take home at the close of a solitary delivery group by using a complete electric health record (EHR), or it can take residence at the close of an external third party, such as a payer, that can syndicate rights data from manifold providers.

An instance of the previous is application of KP HealthConnect, a scheme that mixes the electronic medical record with actions, registering, and promoting, connecting amenities and given that doctors and patients with connected admittance to scientific info 24 hours per diurnal. Additional instance is the Veterans Health Info Schemes and Technology Construction, which assimilates patient archives and managerial statistics to deliver physical time statistics admittance crosswise more than 140 healthcare services and 900 doctors through the United States and in numerous U.S. regions.

Instances of multi-organization schemes comprise the Cancer Investigation System, backed by the Nationwide Cancer Organization and the HMO Investigation System, and the American Medicinal Collection Connotation’s cooperative folder of a million patient archives. All of these organizations have in mutual not impartial the aptitude to collective information but also the investigative volume to establish and recover information in beneficial conducts. To response the enquiry of how healthcare distribution governments can permit the cohort and use of indication, semi-structured interviews were showed with subdivision memberships and other specialists from pertinent governments.

Over the sequence of these consultations, two over-all melodies arose:

-important information combination is dangerous, and info expertise is important to such combination; and

-healthcare governments necessity to have a philosophy of by means of ordinary healthcare distribution as a knowledge instrument and a means of producing indication.

Altogether of these schemes have in mutual not just the aptitude to collective information but also the logical volume to establish and recover information in valuable habits. Quick knowledge health schemes are those that can syndicate the scientific knowledges of their patients in a searchable file that can be used for investigation. Such government’s interpretation each patient conference as addition to the shared information of the collection and as a resources to test a theory so that others in the collection can advantage from the information that is made.

Answer 2

Use of electronic health records (EHRs)is becoming more and more common. It is anticipated that their use will improve patient care, decrease practice costs, and increase provider productivity and revenue. Electronic health record (EHR) systems enable hospitals to store and retrieve detailed patient information to be used by health care providers, and sometimes patients, during a patient’s hospitalization, over time, and across care settings. An EHR creates a database of information that will assist in the coordination of patient care and improvement of communication about shared patients among health care providers.

Benefits of using EHRs can include, but are not restricted to, reduced paperwork for patients and doctors, expanded access to affordable care, improved patient quality of care, prevention of medical errors, decrease in health care costs, increase in administrative efficiencies, and engagement of patients/families in their own health care. An EHR converts a paper medical record into electronic format for faster communication, recall, and clinical decision-making. The goal of clinical decision support is designed to deploy electronic and non-electronic tools to effectively make use of best practices and evidence-based guidelines to help guide care in a more timely manner. Furthermore, the use electronic health records fundamentally changes a practice's communications by redesigning workflows that allow for better access to patient information almost immediately. EHR features include the ability to collect and update patient information that is not consistently provided or documented in all hospitals, including a complete medication list and a medication allergy list, smoking status, and demographic data such as preferred language. The hospitals’ patient portals enable patients to schedule appointments, ask questions of their physicians, view test results, and order prescription refills. Transcription costs will be reduced, patients with specific conditions can be more quickly identified and clinical decision support tools will be in place.

There are significant privacy and security requirements which need to be satisfied. The needs of both patients and health care providers must be addressed. This is essential, challenging, and achievable. Information privacy in health involves optimising individual rights and public good. The benefits expected include:

• Improved clinical decision making
• Reduced duplication of diagnostic testing, imaging and history taking
• Better medication management
• Increased adoption of screening programs and preventive health measures

As a consequence of these projected benefits, the quality of individual care can be expected to improve substantially.

General practitioners/family physicians should have access to all important health data of their patients. A Comprehensive Electronic Health Record System (EHRS), safe and effective comminication with other health care providers is the basis of quality and health care development.

The best model of key capabilities of the Health Information System (Electronic Health Record System included) must be defined. Most EHRS are enterprise-specific(e.g., operate within a specific health system or multy hospital organization), and only a few provide strong support from communication and interconnectivity accross the providers of the community. There have been different views of what constitutes certain types of data, such as medication and various results. Some EHRS provide decision support (e.g. in preventive services, alerts on potential drug interactions, clinical guidelines-driven prompts, etc). Thus EHRS are actively under development and will remain so for many years.

To be most useful, a functional model of a EHRS must also reflect a balance between what is desireable and what can feasably be implemented immediately or within in a short timeframe. It will be important to update the functional model from time-to-time to reflect the advancements in healthcare technology and care delivery.

The core functionalities of an electronic health record can be categorised into:

• Health information and data
• Results management
• Order entry – order management
• Decision making expert systems
• Electronic communication
• Patient support (Patient education/information)
• Administration processes
• Reporting & population health statistics, etc.

Electronic Health Record System with a defined dataset:

• Demographic (unchangeable, changeable data)
• Patient’s problem list (i.e. medical/nursing diagnoses)
• Risk factors
• Medication list
• Allergies
• Laboratory tests, etc.

This ensures better access to the information when needed.

It is important to note that too much information and data can overwhelm or distract the user. Electronic Health Record Systems must therefore have well designated interfaces.

The main objectives of an EHRS in GP/FM are:

• To improve patient safety
• To support effective and efficient health care delivery
• To facilitate management of chronic conditions

Chronic diseases are now the leading cause of illness, disability and death in Europe. Many patients with chronic disorders may not receive the best possible care. They have different health care providers, and thus may receive conflicting information or undergo duplicate tests or/and procedures.

The program enables GPs (General Practitioners) /FPs (Family Physicians) to coordinate care of patients with chronic diseases, being aware of that lack of coordination may lead to poor outcome.

Ensuring Documentation Integrity
Documentation integrity involves the accuracy of the complete health record. It encompasses information governance, patient identification, authorship validation, amendments and record corrections as well as auditing the record for documentation validity when submitting reimbursement claims. EHRs have customizable documentation applications that allow the use of templates and smart phrases to assist with documentation. Unless these tools are used appropriately, however, the integrity of the data may be questioned and the information deemed inaccurate—or possibly even perceived as fraudulent activity. Established policies and procedures such as audit functions must be in place to ensure compliant billing.

Time’s Ticking for Information Governance
Data quality and record integrity issues must be addressed now, before widespread deployment of health information exchange (HIE). Poor data quality will be amplified with HIE if erroneous, incomplete, redundant, or untrustworthy data and records are allowed to cascade across the healthcare system. Healthcare organizations must manage information as an asset and adopt proactive decision making and oversight through information asset management, information governance, and enterprise information management (EIM) to achieve data trustworthiness.

Summary

Good general practice/family medicine is the basis of efficient health care systems. It will require access to and widespread use of electronic information tools. An integrated health record and information system, although costly and not easy to implement, will offer benefits to doctors and to patients, but also to the national healthcare systems, because better data collection ensures better policy development and better resource allocation

Answer 3

Well, I would like to talk about ‘Diabetacare’ a leading diabetes care provider in the UK, UAE and India. I am quite familiar with their process as one of my friends has taken service from them. The Diabetacare is a 24/7 support provider for all one’s diabetes needs.

Let’s look into the patient information capture process. In this organization, the patient data is captured at different levels according to the plan taken by the patient. For walk-in patients, the front office staff collect the personal information and lead the patient to Diabetes Specialist Nurses (DSN) for the collection of clinical data. Here the DSN create a good rapport with the client and a good nurse-patient relationship is formed. The DSN record the information such as presenting complaints, past medical and surgical history, family history of certain medical conditions and client’s level of understanding about the disease, treatment needs and complications in the Electronic medical record system (EMR).

Another important data to be collected here is the sugar level of different times to understand the trend. All the patients are given a smart glucometer which transfer the sugar reading to Diabetacare’s EMR as and when the patient do a test. The 24/7 support team monitor it and provide support over phone to avoid hypoglycaemia and to achieve glycaemic control. Also the EMR automatically calculate the number of sugar readings received from the patient and match it with the number of strips delivered. This helps to replenish the strips before it gets over.

The patient receive advice and health tips through SMS and app notification and which in turn improve the compliance. All medical professional have access to the patient’s information in the EMR in a controlled manner and that helps the care provider to render quality service to the patient by understanding the patient in a single click and guide them accordingly when a patient approach.

The operational part is quite cool as the technology here takes over much of human work. The sugar readings hit on the EMR will help the doctor and healthcare team to understand the trend and help the patient in frequent (daily) dose changes (titration) of Insulin to reach the glycaemic control fast and to the best combination of dose and drugs without the patient visit the clinic very often. This provide high quality service with improved standard of life as number of hospital visit, duration of hospital stay are reduced to a great extent.