Centers for Medicare & Medicaid Services, Research Paper Example

Background

Health information management strategies have become critical in today’s world, whereby there are significant factors associated with the development of critical outcomes in managing confidential patient and other forms of information. It becomes necessary for hospitals and other healthcare facilities to take the steps that are necessary to ensure that this information is protected in the best possible manner, while also ensuring that it is easily accessible to those that require it on a regular basis. Therefore, strategies must evolve to ensure that users are supported with systems that are friendly to navigate, yet also protect data and honor its integrity. The following discussion will address the health information management needs of Mount Carmel West Hospital and the Veterans Medical Center, both located in Columbus, Ohio. This analysis will consider the challenges that are prevalent in managing information management technologies across these two systems, and will demonstrate an effective understanding of the primary issues that preclude the effective utilization of these systems and the needs of their users. These efforts are critical in supporting the overall objectives of this process as a whole, and will recognize that there are strengths and weaknesses, as well as limitations that influence these opportunities in different ways. Alternatives in this capacity must be made with intelligence and knowledge of the requirements of the field, as well as the necessity to protect patient information at all costs to ensure quality performance and patient care at all times. The discussion will also compare and contrast systems at Veterans Administration Medical Center and Mount Carmel West in order to obtain additional insights into these outcomes.

Mount Carmel West Hospital has emerged as a leading healthcare provider in Central Ohio, and serves as an exemplary institution in offering a variety of healthcare and treatment options to patients within this region and beyond (Mount Carmel, 2010). The primary information process at Mount Carmel is formally known in-house as Physician Information Systems, and utilizes NextGen Enterprise Practice Management to manage information and patient records (Mount Carmel, 2010). This process is designed to provide effective insights into different areas, and is based upon the notion of providing effective information strategies for long-term growth and opportunity. Information management systems at the Veterans Affairs Medical Center in Columbus and across all VA facilities as a whole necessitates a comprehensive patient record system with maximum protection of veteran patient information as best as possible. Health information technology is essential to the VA’s mission and vision, and represents different ideas and expectations in regards to protecting patient information in an effective manner (US Department of Veterans Affairs, 2010). The VA utilizes the Veterans Health Information Systems and Technology Architecture (VISTA), which may best be described in the following manner: “VISTA is built on a client-server architecture, which ties together workstations and personal computers with graphical user interfaces at Veterans Health Administration (VHA) facilities, as well as software developed by local medical facility staff” (US Department of Veterans Affairs, 2010). This process is of critical importance in developing an effective series of approaches to manage patient information while protecting confidentiality, while also exploring new uses for the system on a regular basis (US Department of Veterans Affairs, 2010).

In general, patient information systems must be adept to provide high-quality data, free of medical errors, and must also consider models that are designed to support the well being of all patients, regardless of their healthcare needs (Smolij and Dun, 2006). To be specific, ”Accurate and timely health information is a crucial element in the medical decision making process during a medical encounter. Inadequate or misleading patient health information can lead to medical errors, inaccurate decision making, and increased cost. Providing physicians with access to every detail of a patient’s medical history is difficult. Striking the balance between adequate and effective amounts of information is difficult” (Smolij and Dun, 2006). These findings suggest that management information systems require effective approaches that support the best interests of patients over the long term (Smolij and Dun, 2006). Therefore, electronic health records and related document imaging processes are essential in order to accomplish these objectives in an effective manner (Lander and Daniel, 2010). These processes integrate many aspects of a patient’s comprehensive health record from a variety of sources, and thereby demonstrates that information management techniques require multi-system functionality at different levels across a given healthcare organization (Lander and Daniel, 2010). For Mount Carmel West Hospital in Columbus, there is a significant emphasis placed upon the necessity for an efficient yet cost-effective mechanism for managing electronic health records, and this is supported by a series of approaches that are designed to promote these needs, while also protecting patient information from unnecessary risk or harm.

User Needs

The primary users of the electronic health record at Mount Carmel West Hospital are physicians and nurses, respectively. It is believed that individuals acting in these professional capacities require an effective understanding of how patient data and information is collected and retrieved, and also supports the necessity to support patient information needs with convenience and ease. One of the key factors in promoting this process is the following: “The more structured the data coding demanded by the system, the more knowledge and discipline are required from the provider entering the data, and the more efforts within the organization are required to manage the structure and code vocabulary/nomenclature being used” (The MITRE Corporation, 2006, p. 4). In this context, it is observed that organizations require effective electronic records management as a means of promoting the best possible patient care across healthcare disciplines (The MITRE Corporation, 2006). It is important to develop these strategies in response to the challenges that are evident in providing adequate healthcare delivery to all patients, and this is effectively accomplished through full support of electronic health record systems. Most organizations, including Mount Carmel West Hospital and the VA Hospital of Columbus continue to move in this direction towards an efficient system that supports patient confidentiality at all times.

There are a number of advantages and disadvantages in utilizing electronic health record systems. The concept of Electronic Data Capture (EDC) requires further investigation, and necessitates the development of basic data standards for use (Kush, 2006). Both systems at the VA and Mount Carmel capture EDI in their systems in different ways. In this context, it becomes necessary to evaluate how healthcare providers view electronic health records and related systems in order to ensure that these serve as key components of the entire process, and that their full support is acquired (Kush, 2006). For Mount Carmel West Hospital, electronic health records must capture a patient’s health history within the system, including all patient visits, tests, medications prescribed, and other factors that will support a comprehensive analysis of a patient’s health record. This level of information will ensure that a patient is provided with the best possible opportunity to receive satisfactory care and treatment under a variety of conditions and circumstances. Therefore, EDI is a useful tool in developing this process and in capturing data effectively.

For Mount Carmel West Hospital, electronic patient information management is a key priority for the present and the future, one that reflects that patient information must be protected from unnecessary risk or harm, while also being easily accessible and comprehensive at the same time. To be specific, “The electronic health record (EHR) provides the opportunity for healthcare organizations to improve quality of care and patient safety. “The greatest challenge in the new world of integrated healthcare delivery is to provide comprehensive, reliable, relevant, accessible, and timely patient information to each member of the healthcare team, whether in primary or secondary care and whether a doctor, nurse, allied health professional, or patient/consumer” (Schloeffel et al. 2)” (Gurley, 2010). The requirements at Mount Carmel West are similar, and thereby necessitate an effective series of approaches that ultimately support the manner in which patient care is provided across different disciplines. In this capacity, the organization will succeed in its objectives to provide exemplary patient care to a diverse population group, and will also support overall healthcare delivery improvements as a whole. Therefore, in order to achieve these requirements, it is recommended that Mount Carmel West Hospital continue to improve upon its current strategies to promote electronic health records management, including but not limited to the protection of said data and information, while also promoting successful outcomes relative to patient needs and treatment alternatives across a variety of disciplines. This process will ensure that patient satisfaction and the best possible outcomes are achieved.

Analysis

The applicability of an electronic health record system must incorporate a cross-disciplinary process in order to achieve desirable results. Therefore, the basic concepts of developing effective outcomes with electronic health records systems must incorporate a number of different outcomes that support long-term sustainability within this area of interest. The following capabilities are possible with the electronic health record system: “The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting” (HIMSS, 2010). These processes are integral to the overall development and growth of a given system of this nature, and must fully adapt to different scenarios and outcomes that reflect long-term growth, as well as the capability to promote improved patient well being over time (HIMSS, 2010). In this capacity, there are significant factors to consider when addressing these outcomes, and at Mount Carmel West Hospital, the objectives are similar.

With the use of electronic health record systems, it is essential to develop new outcomes and expectations in regards to patient care and related needs. This process supports a greater understanding of the challenges that are evident in facilitating change and progress within organizations such as Mount Carmel, but also represents new opportunities to explore different levels of growth and development, while simultaneously promoting efficiency and sustainability. With these systems, reducing the number of errors in data, as well as limiting duplicity in testing and other forms of treatment are the preferred method of doing business, thereby creating an optimal level of efficiency within this type of system that promotes long-term growth and effective capabilities (Centers for Medicare & Medicaid Services, 2010). Another factor to consider with electronic health records is that patients will possess greater access to their own health data and information, which could facilitate an improved understanding of their health needs over time (Harmon, 2010). However, it should be noted that “There is still a crucial place for health care providers in managing the onslaught of information, but they should act more as data docents. “We need to guide the patient,” he said, but they will no longer accept being barred from the decision-making process” (Harmon, 2010). These processes will ensure that patient records are more openly acquired, while remaining adhered to the standards of the electronic health record system and its mission to protect patient confidentiality and promote data integrity under many different circumstances (Harmon, 2010). Nonetheless, the applicability of these systems requires an effective understanding of how hospitals and other healthcare providers utilize electronic health records in routine activities that involve maximizing patient care and needs assessment processes.

Conclusion

For Mount Carmel West Hospital, there is a significant push to develop and to sustain effective electronic health record systems in an effort to provide the best possible patient care to all persons. It is necessary to consider that current systems have evolved to accommodate these needs in many effective ways, but that there is always room for improvement in supporting these processes. It becomes very important for leaders and managers within the system to regularly examine their electronic patient record systems in an effort to develop new opportunities for growth, while also ensuring that patients are provided with the best possible outcomes with respect to patient care, treatment, and diagnoses. With these principles in place, it is possible to develop and to adapt to system developments as needed, and to consider other opportunities to expand electronic health records systems on a regular basis. Mount Carmel West Hospital must also consider how the challenges of electronic health records require its employees to be trained on these systems on a regular basis, and to develop a greater understanding of the issues that are most relevant in supporting desirable needs and outcomes for all patients. Therefore, employees must understand their role in this process, and must demonstrate that they possess the knowledge and skills that are necessary to produce effective electronic health records management under a wide variety of circumstances. These alternatives are imperative in supporting patient needs above all others. In this capacity, the organization possesses a responsibility to provide patients with effective care and treatment, and this is best accomplished through an ongoing intervention that will support effective results on a consistent basis. With these principles in mind, it is important for Mount Carmel West hospital to seek recommendations regarding these systems, and to adhere to these recommendations as needed so that patients are provided with the resources that are necessary to support effective results under a variety of conditions. Patients must serve as the primary focus in these endeavors, and therefore, clinicians at all levels must demonstrate professionalism and knowledge of these systems so that these objectives are accomplished as best as possible. This process will ensure that the hospital is putting its best efforts forth to accomplish these objectives in a successful manner. Each facility under consideration must continuously explore its alternatives in producing successful results that will encourage patient confidentiality at all times.

References

Centers for Medicare & Medicaid Services (2010). Electronic health records: overview. Retrieved April 13, 2010 from http://www1.cms.gov/EHealthRecords/

Gurley, L. (2010). Advantages and disadvantages of the electronic medical record.

Retrieved April 13, 2010, from http://www.aameda.org/MemberServices/Exec/Articles/spg04/Gurley%20article.pdf

Harmon, K. (2010).Moving forward with electronic health records. Retrieved April 13, 2010, from http://www.scientificamerican.com/blog/post.cfm?id=moving-forward-with-electronic-heal-2010-02-05

HIMSS (2010). HER: electronic health record. Retrieved April 13, 2010, from http://www.himss.org/ASP/topics_ehr.asp

Kush, R. (2006). Electronic data capture – pros and cons. Retrieved April 13, 2010, from http://www.cdisc.org/stuff/contentmgr/files/0/f4a101334fce295d85828d036c06991b/misc/bei26kushsup.pdf

Lander, M.L., and Daniel, A. (2010). The journey to the electronic health record. Retrieved April 13, 2010, from http://www.infotivity.com/dynamic.htms

The MITRE Corporation (2006). Electronic health records overview. Retrieved April 13, 2010, from http://www.ncrr.nih.gov/publications/informatics/ehr.pdf

Mount Carmel (2010). Physician information systems. Retrieved April 13, 2010, from http://www.mountcarmelhealth.com/medical-professionals/office-services/physician-information-sy.html

Smolij, K, and Dun, K. (2006). Patient health information management: searching for the right model. Retrieved April 13, 2010, from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_032723.htmls

United States Department of Veterans Affairs (2010). VA health information technology improves quality of health care while reducing costs. Retrieved April 13, 2010,  from http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1880

United States Department of Veterans Affairs (2010). Veterans Health Information Systems and Technology Architecture. Retrieved April 15, 2010, from http://www4.va.gov/vista_monograph/