Camden Nursing Facility, Research Paper Example

Overview of Organization

Camden Nursing Facility is a certified 95-bed health care institution operating at full capacity 90 percent annually. This is a for-profit, religious affiliated operation. The facility has on-site clinical laboratory services and provides physical and occupational therapy, podiatry, speech/language services as well as mental health and dental services to the residents of Camden Nursing Facility.  Physician services are provided on and off-site to the residents with a pharmacy on-site. X-ray services are provided off-site. Dietary and housekeeping are also provided. This organization participates in Medicare and Medicaid programs.  Registered nurses and licensed practical nurses provide around the clock coverage.  Certified nursing assistants are also employed at Camden Nursing Facility. Information technicians also monitor the electronic systems and provide support and training.

Medical Records

Camden currently underwent conversion from paper to electronic medical records. The specific purpose of going paperless with medical records and storing all information electronically is patient privacy. Electronic medical records are also effective and provide advanced technological options for ease of use and improved communications. Electronic medical records, when properly implemented, will ensure secure and private medical information. The conversion process is enormously complex and must meet set standards and guidelines of the facility and governmental laws through HIPAA and other laws and regulations geared to provide security and privacy. Several phrases are used to define the electronic records; continuity of care record (CCR), electronic medical record (EMR) and electronic health record (EHR) (Oatway, 2004).

The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the United States Congress in 1996 specifically to deal with the guidelines, standards, and processes for converting from paper to electronic formats. The Administrative Simplification Compliance Act (ASCA) amended the HIPAA law and further required that all health insurance claims submitted to Medicare by October 16, 2003 and beyond to be done so electronically (CMS, 2010).  HIPAA sets the standards and the law is specifically geared at patient privacy protection. Electronic medical records, as well as insurance claims specifically combats waste, fraud and abuse in health insurance, health care delivery and promotes improvement to long-term care services and coverage CMS, 2010).

Electronic medical records in long-term care facilities are different from acute-care settings. In nursing facilities the nature of information is extensive and entails various provider communications. In an acute-care setting the focus is more on establishing a diagnosis and treatment modality.  Nursing facilities have larger records on each individual patient. Historically when the law originated software was created which accommodated acute-care settings and did not take other setting into account. Through time the needs of other health care settings became known and data-management technology began to increase and expand to accommodate all types of settings.

Clinical and Administrative Applications

Camden reviewed many types of applications to ensure the purchase of the type which would allow flexibility to accommodate the needs for the various different providers and nursing personnel. One key function the organization specifically liked was the fixed field position which limited errors and created a uniform approach to how information is filled into the specific fields. This applies to both the clinical and administrative capabilities of the software.  By using this XML technology it provides the auspices to make system changes easier for providers to accomplish and maintain (Oatway, 2004).

The key features are important and the faculty and staff must accept the software for it to be utilized effectively and efficiently. If the software specifics are too cumbersome to use, faculty and staff will reject them, become frustrated and documentation integrity is the resultant issue. At Camden clinical stations and mini laptops are used so the faculty and staff can have the electronic modality at hand when seeing patients. Laptops are the predominate hardware used by the staff. They are able to access each record in real time and enter data into the patient’s record as the visit/examination is being conducted.  Although this is the most efficient method, some patients are not happy with their clinician typing on the keyboard during their conversation.  They feel the nurse or doctor is not listening to them and must continually be reassured that they are listening and typing in the patient’s condition in the most private manner available (Oatway, 2004). Explaining privacy and HIPAA rules to the patients and their families has helped foster acceptance by the patients.

During the research and investigation of providing laptops, administration conducted benchmarking and price comparison to determine cost versus productivity. Including technology in the facility’s budget became a necessity to be able to benefit from the investment and remain compliant to HIPAA regulations and laws. Increasing the use of technology and anticipating significant reduction of medical errors and other savings outweighs the costs of the laptops. Nursing facilities can expect to benefit from the use of electronic records through efficiency, reduced claim rejections, improvement documentation and more informed and coordinated clinical processes (Oatway, 2004).

Networks

The use of the laptops increases the user needs and data exchange for quality processes and excellence in patient care.  The medical record is instantly updated in real world time by the input of data during the patient/clinician exchanges. The software also contains diagnosing terminology to be able to assign the diagnosis during the exchanges for accuracy in the patient’s conditions. Standardizing clinical terminology into the systems is one way to facilitate the exchange of health care information electronically (Lehmann, 2003).

Currently the network at Camden is limited to this facility only. However, consideration has been given to a proposed network with community hospitals associated with Camden. This proposal would link together existing regional electronic medical record networks with a new infrastructure and programming with set policies to govern the implementation and maintenance (Healthcare Informatics, 2010). This would serve not only the facility of Camden but would provide access to other facilities for collaborative interchange for the safety and quality care of patients. Off-site facilities would benefit from having access to the patient’s records when the individual must go off-site for care not provided on-site.

Data is maintained by information technologists who ensure the integrity of the system, guard against computer viruses and keep in compliance according to HIPAA regulations. Medical records and health information technicians assemble patients’ health recordings including medical history, symptoms, exam results, diagnostic tests and treatment methods, ensuring the quality, accuracy, accessibility and security (Department of Labor, 2010).

Training

Initial training for the faculty and staff after implementation of the electronic medical record software was conducted by the company Camden purchased the equipment and software. Staff development plays a crucial role in supporting clinicians and staff to adapt to the ever changing technological advances in the healthcare setting (McCain, 2008). Supporting faculty and staff with continual training and support is important to the acceptance of using electronic medical records.

Ongoing training is done by peer training and assistance from the information technicians on-site employed by Camden.  There are also on-line self-paced tutorials which staff can use at any time they feel they need additional information or have questions.  Anytime there are software updates, training sessions are held at various times of the day to ensure all staff and faculty have the opportunity to attend. The software package itself is relatively easy to use, however, training and updates are required to formally educate the users on the specifics of the features.  With round-the- clock staffing schedules, the times offered vary to accommodate all participants. Providing ample opportunities for training allow staff the flexibility to participate without hardships to their schedules. Camden also uses feedback through evaluation surveys to measure the effectiveness of the training sessions.  This information allows for quality changes to the instructions and teaching methods to create successful learning environments.

Privacy and Security

Electronic records are specifically designed to provide privacy and security of information of a patient’s logistics, health status and personal information. HIPAA privacy requirements are essential to gain professional and public trust in the electronic record (Oatway, 2004).  While any record, paper or electronic, can be compromised, the electronic record has technology to help safeguard against invasion of privacy. Paper records are easily compromised; however, electronic records require an intentional intrusion by a person. Moving away from paper records ensures that files are not left out in the open for anyone to view.  Staff must be sure with electronic records to watch the computer screen access and never leave an unattended computer monitor or laptop to be viewed by the wrong person.

Each staff member has their own unique pass codes and an electronic history is created detailing the person logging in and which records they view. This is one security feature which legally documents the intrusion into a patient’s record inappropriately. Staff should only view the record of the patient they are caring for; not the family friend or old neighbor out of curiosity or request by others. Camden is very careful to train and monitor the medical records for privacy and confidentiality. Regular and random monitoring is performed by the information technicians to ensure privacy quality and adherence to HIPAA.

If any staff member suspects integrity issues, an anonymous HIPAA hot-line has been created for reporting confidentially. To ensure total compliance with security and privacy it is everyone’s responsibility to be compliant and to report any fraudulent behaviors. Anyone suspected of misconduct will be interviewed and an investigation performed.  If an intentional attempt to invade privacy has been determined the employee is terminated immediately. If the invasion was determined to be an error or honest mistake the employee is counseled. Camden has made a commitment to their employees, staff, residents and resident’s families to provide the most efficient system to protect against invasion of privacy. The organization takes this responsibility very seriously and works on a continual basis to protect the residents at Camden Nursing Facility.

Conclusion

The successful development, planning and implementation of an electronic medical record system at Camden Nursing Facility has thus far proven to be a valuable asset to the organization. Clinically and administratively the system has demonstrated the well-organized and valuable process to the privacy and safety of patient information.  The organization has implemented a network with training for staff for a thriving system which is easy to use and highly secure.

References

CMS (2010). The HIPAA Law and Related Information.  Centers for Medicare and Medicaid Services.  Retrieved from https://www.cms.gov/HIPAAGenInfo/02_TheHIPAALawandRelated%20Information.asp#TopOfPage

Department of Labor (2010). Medical Records and Health Information Technicians. Retrieved from http://www.bls.gov/oco/ocos103.htm

Healthcare Informatics (2010). New York to Create Largest Electronic Medical Record Network. August 28, 2010.  Retrieved from http://www.healthcare-informatics.com/ME2/dirmod.asp?type=news&mod=News&mid=9A02E3B96F2A415ABC72CB5F516B4C10&tier=3&nid=2C5ED97A2BA642678A6CD6739ABAFFE8

Lehmann, C. (2003).  Medical records database efficient but troubling. Psychiatric News, Vol 38, No 15; August 1, 2003. Retrieved from http://pn.psychiatryonline.org/content/38/15/5.1.full.

McCain, C.L., (2008). The right mix to support electronic medical record training: classroom computer-based training and blended learning. Journal of Nurses Staff Development, July-August, vol 24, no 4:151-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18685473

Oatway, D. (2004). Electronic records in long-term care. Nursing Homes, September, 2004.  Retrieved from http://findarticles.com/p/articles/mi_m3830/is_9_53/ai_n6230147