Introduction
This guide comprises of frequently asked questions regarding Electronic Medical Records (EMRs) and that are likely to elicit debate concerning how caring and technology can coexist in nursing care delivery. The guide consists of 10 open-end queries and expected responses. The purpose of this guide is to enable quick understanding in issues relating to EMRs. Also the guide enables effective training on the implementation of an Electronic Medical Record system. The questions in this guide are:
EMR Description
Electronic medical records are generated electronically and maintained over long periods being reactivated with each patient encounter. Past medical information that was previously gathered and recorded is readily available and able to be updated speedily, providing a comprehensive record of each patient’s involvement with that particular institution.
EMRs are individualized and designed for specific healthcare users. For example, a pediatrician’s EMR would include items like vaccination dates and developmental milestones, while an obstetrician’s EMR would include a woman’s LMP & EDC. Additionally, a large institution like a hospital may have many different ancillary departments included (OR short stay, ER visits, radiology & In-patient) while also having various areas in the patient record for laboratory results, vital signs, etc.
However, EMRs are generally not shared between separate institutions. As stated in the NIH’s publication, electronic health records overview (2006), “An EHR [electronic health record] is not a longitudinal record of all care provided to the patient in all venues over time.” It is maintained by one institution and is longitudinal in nature specific to a patient’s involvement with that institution.
Hardware used with EMRs
- Desktop – This is the most common hardware utilized with EMRs. It is a computer system that usually consists of a tower, screen and keyboard.
- Server – maintains EMRs availability within an institution’s network.
- Tablet PC – Can be carried by healthcare users; input can be from keyboard or stylus. It can be used with specialty software including handwriting recognition software.
- Router – If the institution is using wireless networks, then a router is necessary
- Backup Hardware – According to Cavolo (2007), an institution is smart in purchasing backup hardware because they should, “Always think disaster avoidance.”
Software used with EMRs
- Specialty specific programs are available for many different specialties: OB, Peds, ER, Radiology, Oncology, etc.
- According to Staggers (2003), the usability of computer interfaces is important to consider, especially regarding areas of ease of use, learning and remembering and user satisfaction.
- Additionally, one must consider the lab interface’s ability to interface with the institution’s existing EMR system.
- Lab interfaces incorporate lab results, generated in the laboratory, into the EMR software system being used by the institution. The EMR would have specific areas and one would automatically pull in the patient’s lab values. The healthcare provider then wouldn’t have to manually input the lab values into the EMR, and the lab values would be immediately be obtainable when available.
- eLab is by Powered. Information can be found at: http://www.powermed.com/products_services/elabs.html.
Ethical/Legal Issues with EMRs
- Personal Health Information (PHI) is more vulnerable to breaches in confidentiality. First, sharing of Personal Health Information is a breach in confidentiality. Sharing patient information is unethical and against the nursing profession. For example, revealing the health status of a patient to irrelevant people is a breach and affects not only the patient trust but also the nursing profession. This new system would follow the HIPAA laws and would ensure data security through providing reasonable measures for controlling data leakage i.e. through offering secure network and user security. Also, Errors- the new system will use e-lab that ensures efficient tracking and identify errors/problems based on QI data.
- Breaches of confidentiality, in fact, have been widespread, if not ubiquitous. In some instances, breaches occur within the parameters of present law: Pharmacies in some states legally sell individual prescription records to pharmaceutical companies for use in marketing campaigns.
- The flow of medical information carries numerous personal and societal benefits. The ability to access medical records has saved the lives of unconscious patients brought into hospital emergency rooms. Pharmacists have detected dangerous, sometimes potentially lethal, drug combinations. In the public health arena, computerized records have made possible the prompt detection of infectious disease epidemics and enabled health authorities to take emergency action. Researchers have used databases to analyze the causes of illnesses, a process that, for instance, established the connection between smoking and lung cancer.
On the other hand, the vast accumulations of personal medical data give rise to serious privacy concerns as a result of the potential for misuse. As a national magazine recently noted.
Under HIPAA’s Security Rule
Covered entities must implement a regime of information system access controls as part of their technical safeguards, complementary to the facility access controls that are part of its physical safeguards. The access controls at issue here are defined as “technical policies and procedures for electronic information systems access that maintain electronic protected health information (e-PHI) to allow access only to those persons or software programs that have been granted access rights as specified in” the information access management standard of its administrative safeguards.
The access control standard has four implementation specifications.
The first two are required and the last two addressable:
- unique user identification;
- emergency access procedure;
- automatic logoff; and
- encryption and decryption.
Errors
The new system includes information about administrative data; coding from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM); assignment of DRGs and Major Diagnostic Categories (MDCs); and specific definitions for adverse events or complications, preventability, and medical error. Candidate measure information incorporated exclusion and inclusion criteria, the clinical rationale for the indicator, and the specification criteria.
Roles of Implementation Teams
The implementation team includes:
- Project Manager (PM) –The project manager will lead the implementation team and is responsible for project control and resource coordination.
- Application Administrator– Responsible for configuration and support.
- IT Support – IT is responsible for your hardware and software systems performance and availability.
- Reporting Analyst – Ensures needed data items are collected and reportable long before the reports are built in the new system.
- Super-users: Ensuring the system works efficiently and effectively for all health center tasks (Cavolo, 2007).
References
Cavolo, J. (2007). Electronic medical record systems: know the total cost of ownership; Like other IT, EMR systems have basic expenses. But what other financial outlay should you expect with implementing this new technology? Nursing Homes. Web.
Milne, M. (2006), HIPAA in a “Nutshell” – Guidelines for EMR and Paper Medical Records Compliance. Web.
McGonigle, D.& Mastrian, K. (2009). Chapter 13: Overview of nursing informatics. Nursing Informatics and the Foundation of Knowledge. Boston: Jones & Bartlett Publishers.
Smallwood, B. (n.d.). What Healthcare REALLY Needs to Know About Managing Electronic Documents. Web.
Staggers, N. (2003). Human factors: Imperative concepts for critical care. AACN Clinical Issue. 14(3), 310-319.