Question

Chapter 16. Case Study on p. 283

Book: Healthcare Informatics: An Interprofessional Approach 2nd edition.

You’ve been chosen to participate in the selection team for a new clinical information system to be purchased and implemented at the community hospital where you are a staff nurse. The selection team has been asked to develop an initial list of requirements that they would like to use for the evaluation of potential systems in relation to the documentation of assessments for interprofessional use, including nursing, physician, other ancillary departments like physical therapy and occupational therapy. The selection team has decided to group the requirements that they identify into the following categories:

• Patient care objectives
• Usability
• IT department objectives
• Organization objectives   

Your task for this case study is to use the key considerations listen below to develop a list of system requirements for electronic documentation in a clinical information system, grouping the requirements into the four categories listed above. The key considerations include information that the selection team has gathered in anticipation of developing system requirements.

Key Considerations for System Selection
Findings from Inventory of Current Systems Functionality

• Electronic laboratory and radiology report results are produced by ancillary information systems.
• The intensive care units (ICU’s) have an ICU information system where some documentation is done electronically, including vital signs, intake and output, and some interfaced data from monitoring systems.

Findings from Inventory of Paper Documents and Forms

• Nursing notes and care planning are documented on paper in the medical/surgical units.
• Physician progress notes and orders are on paper.
• Numerous paper forms exist and there are various versions of forms in use with no consistency across the organization.
• Paper order sets are in use. Some order sets are physician-specific, with multiple versions for the same diagnosis or procedure. None appear to be evidence-based.

Findings from Staff Interviews and Observations
Direct observations studies were conducted in the ICU, medical/surgical units, and pediatric units. Observations and interviews were also conducted in various other clinical departments including Physical Therapy (PT), Occupational Therapy (OT), and wound care. The study revealed that there are similarities in the types of data collection in all of these areas. Key findings included the following:

• Need to be able to document using structured data such as pre-defined drop-down boxes.
• Need to be able to enter free-text comments.
• Entry of an electronic assessment must include the user’s electronic signature and current date and time.
• All entries must have the capability to be edited, and changes to the document must be tracked by the system.

SWOT Analysis
A SWOT analysis of the current documentation was conducted with the following findings:

• Strengths. Structured electronic data in the ICU facilitates accurate and timely data collection.
• Weaknesses. Lack of standardization may result in inconsistent patient care.
• Opportunities. An electronic order management and documentation system could support evidence-based practice methodology.
• Threats. Paper documentation is difficult to read and could result in patient safety issues.

Answer 1

For the electronic documentation in a clinical information system there is the need of most modern electronic equipments which can use for the effective running of the firm. From the reception or front office it self can start its use. as we know when a patient comes to the clinic its easy and usefull to register his personal details regarding with his health condition and the doctor whom he consult etc.... if there assign a unique number for the patient and it entire to the hospitals data entry system. it will be easy to find his clinical information on his condition. it can use in laboratory for any medical tests or in consultation room even in icu cases also. for all this we must need the strong information system and computer connections, network and value added services etc...

SO many equipments can be used in to in each departments in hospitals, for example   * diagnostic equipments like- Medical imaging machine like x-ray, CT, MRI, USG Etc..

*durable medical equipments - manual wheel chairs and electric wheel chairs, walkers, traction equipments, pressure mattresses, insulin pumps , nebulizers, oxygen concentrators ventilators, kidney machine etc...

*treatment equipments- infution pumps, lasic surgical machines, medical lasers, diagnostic scopes etc...

life support equipments- heart lung machines, medical ventilators, dialysis machines, incubators

medical laboratory equipments- blood gas analyzers, chemistry analyzers, blood collection supplies, electrolyte analyzers, drug testing analyszers, hematology analyzers,micro biological system etc...

these are the equipments used in hospitals

In a hospitals and clinic all the procecure rooms , consulting rooms all, the equipments are should be connected, if any emergency occures the patients information sholud get in texture that means data should be enterd in a simple and effective way.