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Electronic Health Record,[object Object],Jessica Austin - Slides 3-13,[object Object],Shaun Baker - Slides 18-33,[object Object],Kayla Boro - Slides 14–17, 34-38, 39, 41,[object Object],Victoria Blankenship - Slides 1-2, 40, 42-44,[object Object]
Introduction ,[object Object],Some of us have been nurses for several years and others are just getting their career started. One thing we have in common is we will all be working with computer systems to put in and retrieve data. The following slides are a framework of information to help nurses understand and evaluate the Electronic Health Record (EHR). ,[object Object]
What is a Clinical Information System (CIS)?,[object Object],“A CIS is a collection of various information technology applications that provides a centralized repository of information related to patient care across distributed locations. ,[object Object],This repository represents the patient’s history of illnesses and interactions with providers by encoding knowledge capable of helping clinicians decide about the patient’s condition, treatment options, and wellness activities (McGonigle & Mastrian, 2009).,[object Object]
What is a Clinical Information System (CIS)?,[object Object],The repository also encodes the status of decisions, actions underway for those decisions, and relevant information that could help in performing those actions. The database could also hold other information about the patient including genetic, environmental, and social contexts (McGonigle & Mastrian, 2009) .”,[object Object]
Key players involved in choosing, implementing, and revising a CIS,[object Object],Implementation should involve those who work with patients (end users) to improve the interface, accuracy, and security.,[object Object],Medical Staff/Clinicians,[object Object],Performance improvement analysts ,[object Object],Executive leadership/CEO,[object Object],Key stakeholders,[object Object],System administrators,[object Object],Tech support,[object Object],Education team,[object Object],(McGonigle & Mastrian, 2009),[object Object]
Key players involved in choosing, implementing, and revising a CIS ,[object Object],Implementation of such systems requires that they be designed to interface with legacy systems, privacy and security, and clinician resistance to learning new technology (McGonigle & Mastrian, 2009). ,[object Object]
The 8 ESSENTIAL components of the EHR,[object Object],Health Information and Data,[object Object],The patient data required to make sound clinical decisions. The patient and all healthcare providers should have access to be able to make clinical decisions.,[object Object],Results Management,[object Object],The ability to manage results of all types electronically, including lab and radiology procedure reports, both current and historical. The patient and all health care providers should have access to tie patient results together.,[object Object]
The 8 ESSENTIAL components of the EHR continued….,[object Object],Order Entry Management,[object Object],The ability of a clinician to enter medication and other care orders, including lab, micro, pathology, radiology, nursing, supply orders, ancillary services, and consultations directly into a computer. Physicians and licensed personnel should have access to input orders and patients may view orders,[object Object]
The 8 ESSENTIAL components of the EHR continued….,[object Object],Decision Support,[object Object],The computer reminders and alerts to improve the diagnosis and care of a patient including screening for correct drug selection and dosing, medication interactions with other medications, preventative health, reminders in areas such as vaccinations, health risk screening and detection, and clinical guidelines for patient disease treatment. The patient and all healthcare providers should have access to help make decisions and protect the patient.,[object Object]
The 8 ESSENTIAL components of the EHR continued….,[object Object],Electronic Communication and Connectivity,[object Object],The online communication among healthcare team members, their care partners, and patients including e-mail, web messaging, and integrated health record within and across settings, institutions, and telemedicine. The patient and healthcare providers should have access to allow communication among the members.,[object Object]
The 8 ESSENTIAL components of the EHR continued….,[object Object],Patient Support ,[object Object],The patient education and self-monitoring tools, including interactive computer-based patient education, home telemonitoring, and telehealth systems.  The patient and healthcare providers should have access to patient support. ,[object Object]
The 8 ESSENTIAL components of the EHR continued….,[object Object],Administrative Processes,[object Object],The electronic scheduling, billing, and claims management systems including electronic scheduling for inpatient and outpatient visits and procedures, electronic insurance eligibility validation, claim authorization and prior approval, identification of possible research study participants, and drug recall support. The patient and healthcare providers should have access to allow information to be organized and used for analysis/research.,[object Object]
The 8 ESSENTIAL components of the EHR continued…,[object Object],Reporting and Population Health Management,[object Object],The data collection tools to support public and private reporting requirements including data represented in a standardized terminology and machine readable format. The patient and healthcare providers should have access to share patient information and compare data (McGonigle & Mastrian, 2009).,[object Object]
Clinical Decision Making System in a CIS,[object Object],What is the clinical decision making system?,[object Object],“Tools that provide the clinicians, staff, patient, or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times to enhance health and healthcare (McGonigle & Mastrian, 2009).”,[object Object]
Clinical Decision Making System in a CIS,[object Object],What it needs: Easy access,[object Object],Needs to be user-friendly,[object Object],Keep system up-to-date,[object Object],Follows latest research,[object Object],Evidence-Based practice ,[object Object],Update with all new EBP guidelines ,[object Object],(McGonigle & Mastrian, 2009),[object Object]
Clinical Decision Making System in a CIS,[object Object],Company examples that design CIS systems:,[object Object],Visual Dx,[object Object],Dxplain,[object Object],Diagnosis Pro,[object Object],TheraDoc, Inc.,[object Object],Epic,[object Object],(McGonigle & Mastrian, 2009),[object Object]
Ehr by jessica austin, shaun baker, victoria blankenship and kayla boro
Safety and Security,[object Object],Health information and communication technologies (EHR)applications are set up with volatile degree of knowledge and achievement with the objective of improving health care/ nursing operation, management, patient care, and information management. ,[object Object]
Safety and Security,[object Object],Utilities most widely supported include clinical and administrative email/texting; financial, and human resource procedure and administration; logistical management of health division tasks and patient information and health education. ,[object Object]
Safety and Security,[object Object],Much of past information in healthcare was kept on paper files and stored in cabinets or managers desks, patient information was just a sheet away from being lost or thrown in regular trash, but now technology has our paper locked behind multiple firewalls of electronic data encryption. ,[object Object]
Safety and Security,[object Object],Multiple bits of private personnel data stored in mass computer banks awaiting a hackers fun stop to destroy a company or a persons life.  ,[object Object],Cyber security thus was developed due to the increasing threats to security of patient data from multiple sources that tend on stealing or corrupting data.,[object Object]
Safety and Security,[object Object],Cyber security consist of several forms of security from secondary companies that monitor the internet and intranet for malicious threats such as viruses/worms / and trojans that are developed by outside sources made to steal or corrupt data. ,[object Object]
HIPAA Considerations,[object Object],“Assess and plan communication awareness requirements Develop and plan a HIPAA awareness communication plan Conduct an awareness program to promote organizational involvement Monitor communication efforts for effectiveness Review brochures and promotion items as to how HIPM is mentioned in literature (DHHS, 2003).” ,[object Object]
Safety and Security,[object Object],“Assess and plan communication awareness requirements Develop and plan a HIPAA awareness communication plan Conduct an awareness program to promote organizational involvement Monitor communication efforts for effectiveness Review brochures and promotion items as to how HIPM is mentioned in literature (DHHS, 2003).”,[object Object]
Safety and Security,[object Object],Individuals, as fitting to their professional roles, should be aware of the relevant security risks, required preventive measures, and assume responsibility and take steps to enhance the security of information systems and networks they deal with.,[object Object]
Safety and Security,[object Object],“How individuals gain access to such a secure network makes the network more secure by simply adding the password activated accounts to access patient information and thus adding more security allowing only certain access to certain levels of discipline determined by entrusted individuals to decide who has what access (U.S. Government, 2003).”,[object Object]
Safety and Security,[object Object],Having access to secured cyber space for patient information brings another question of ethics, people who have access should respect the privacy and potential of “not to do any harm” when given special access to information that is not yours. ,[object Object]
Safety and Security,[object Object],When a medical facility chooses a security network to protect their patients its good to consider both a internal team and external team to watch the network and setup security development tools.,[object Object],The network should have rules and regulations built on integrity policies written by the operating facility and enforced by the network team. ,[object Object]
Safety and Security,[object Object],Data from the network should be backed up by separate computing networks with internal saving devices setup to save data materials every five minutes to ensure data will not be lost and then backed up onto a CD drive or digital media as hard copies of the data daily.,[object Object],This ensures data is captured and contained in the system so that it can be accounted for on a timed basis once again ensuring integrity.,[object Object]
Costs/ Finance ,[object Object],EMR in the health care world are far from cheap systems range from hundreds of thousands to millions of dollars, depending on size, information bank, productivity, security, ease of use, and individual training on product use and software.,[object Object]
Costs/ Finance ,[object Object],Compatibility issues also raise cost depending on other equipment and software providers that may have to alter their products to fit or run with the new EHR.,[object Object],Purchasing of EMR’s should be relied upon credibility of the company and a track record along with several studies and test runs of the actual product.,[object Object]
Costs/ Finance ,[object Object],Selecting a product that fits the system needs along with the capability to upgrade or improve in the future along with ongoing education to the staff with each upgrade should be considered.,[object Object]
Costs/ Finance ,[object Object],IT support personnel should also be considered:  What if problems arise? Who will do the upgrades? When will the upgrades occur? Will they affect my staff’s productivity? Who can my staff call when the problem occurs and will they be available 24 hours a day?,[object Object],Many questions should be reasoned with before a purchase of any EHR.,[object Object]
Education,[object Object],“The success or failure of an informatics solution can be directly related to the education that was provided (McGonigle & Mastrian, 2009).”,[object Object],Originally, nurses teaching Informatics had no formal education,[object Object],Acquired Skills by:,[object Object],On-the-job training,[object Object],Attending classes to learn about the system,[object Object]
Education,[object Object],There are formal ways to become an educator.,[object Object],Graduate classes offered at various universities,[object Object]
Education,[object Object],Two certifications that are available,[object Object],American Nurses Credentialing Center Exam,[object Object],Must be an RN/BSN w/ 2 years of experience.,[object Object],CPHIMS(Certified professional in healthcare information and management systems),[object Object],Open to anyone who is involved in healthcare informatics.,[object Object]
Education,[object Object],Many ways education can be implemented,[object Object],Important: Remember everyone learns differently.,[object Object],It is the Educator’s job to:,[object Object],Develop education materials,[object Object],Implement a plan to teach the materials,[object Object],Provide education about the system ,[object Object],New employees,[object Object],System Launch,[object Object],Upgrades,[object Object]
Education,[object Object],Initial education requirements for staff include,[object Object],A basic computer class,[object Object],This helps with staff who are unfamiliar with computers,[object Object],20 hours of education upon implementation of EHR,[object Object],“Super users” are often used to help with the class,[object Object],Show the information as the instructor is talking,[object Object]
Education,[object Object],Updates can be implemented by:,[object Object],Handouts,[object Object],Additional class time,[object Object],Educational computer simulation,[object Object],Many have certificates that print when you complete the cours,[object Object]
Education,[object Object],Example of a handout,[object Object]
Education,[object Object],Technology is always changing,[object Object],It is important that everyone stays up-to-date,[object Object],Additional re-education is determined by each institution ,[object Object],Refresher courses may be needed if the individual has not been familiar with the system for long periods of time.,[object Object]
Conclusion ,[object Object],	Despite the challenges, the future of EHR’s is an exciting one for patient and clinician alike. Benefits may be realized by stand-alone EHR’s as described here, but the most significant transformation will come as interoperability is realized between systems (McGonigle & Mastrian, 2009 ,[object Object]
References ,[object Object],Department of Health and Human Services-HIPAA AdministrativeSimplification informationhttp://aspe.os.dhhs.gov/admnsimp,[object Object],http://cisevaluation.com/uploads/CISESArticle.pdf,[object Object],McGonigle, D. &Mastrian, K. (2009). Nursing informatics and the foundation of knowledge. Sudbury, MA: Jones and Barlett Publishers.,[object Object]
References ,[object Object],U. S. Government (2003) .The National Strategy to Secure Cyberspace.The White House, February 2003. Available online at:http://www.whitehouse.gov/pcipb/cyberspace_strategy.pdf,[object Object]

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Ehr by jessica austin, shaun baker, victoria blankenship and kayla boro

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