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Introduction to Theory in Healthcare Informatics
Temaya Mims
Informatics
Module 1
May 12, 2023
1
Introduction to Theory in Healthcare Informatics
Electronic Health Record and Data Collection
2
Introduction to Theory in Healthcare Informatics
The healthcare world is expanding and advancing every day. There is new material and systems being discovered to help the health system move more efficiently such as the change from paper charting to computer charting. The Electronic Health Record system is the computer charting used worldwide in different hospitals and clinics. Electronic Health Record (EHR) is a digital version of a patient’s paper chart based on real time and is patient-centered records that is readily available to authorized users. EHRs are vital to health IT and contain a patient’s medical history, medications, allergies, test results, treatment plans, radiology images,
immunizations, and laboratory and test results. Even though EHRs have many positive points and quick access, some feel that it takes away critical time from the patients when it comes to documentation. In this paper, we will discuss the lack of focus on patient care when using EHR if
clicking box style documentation is present in sufficient detail in a lawsuit, the use of data, and the ethical concerns of tracking this data by an outside organization-as well as E-learning and nursing theory related to informatics.
The effects of EHRs when it comes to patient care.
The majority of hospitals and health clinics in the world have been utilizing the Electronic health records system. There are many benefits to Electronic Health Records, but there are also some downfalls as well. Some healthcare professionals have opinions that EHRs are time consuming takes away from patient focused care. There is much documentation required when it comes to patient’s information and most healthcare workers attempt to get this done in a timely fashion. (Hoover, 2017) Some charting systems have time-based charting. 3
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Introduction to Theory in Healthcare Informatics
Time based charting is when documentation must be completed by a certain time, or it will be considered missed. Many professionals attempt to obey by the time-based charting but some days that just cannot be possible especially if your patient is having critical care that needs to tentative at time. Some health professionals spend so much of their time on the computer and lose track of time causing them to forget the status of the patient
(Ommaya et al., 2018)
. As I stated in the beginning before there was computer charting paper charting was the primary use
for many years. Many older clinicians and healthcare professionals do not have any easy process of adapting to switching to electronic charting. (Hoover, 2017) Many do not have the skills to learn or maneuver the charting system, which is a big issue in the care and charting of the patient health care service. Because the clinician or healthcare professional does not have the required skills and knowledge on how to operate the computer, it may be very time-
consuming causing them to be in front of the computer for long periods of time and patient care is being neglected.
(Hoover, 2017)
Is patient care suffering from the implementation of EHRs?
When it comes to electronic documentation, so much must be charted such as vital signs every 4 hours, turn schedules every 2 hours, hourly rounding documentation, any changes
noticed in patients or concerns, new orders and the list goes on. Due to the drastic documentation requirement, proficient patient care is challenging because it may put the patient in harms of neglect. Some of the patient’s needs may not be attended to by the nurse or healthcare provider either because of the lack of skills to maneuver the charting system and because of the amount of documentation that is required. These unforeseen circumstances can
ultimately lead to patient and family complaints concerning the patient’s care and needs to be 4
Introduction to Theory in Healthcare Informatics
taken care of.
The complaints will cause negative outlooks and numbers on the facility. This is where the conflicts come into play. The facilities rely on patient satisfaction and reimbursements from the timely charting documentation to help the hospitals or clinics stay open and for funding (Ommaya et al., 2018). One solution to prevent patent suffering from the time-consuming documentation is reducing a lot of redundant charting
(Ommaya et al., 2018).
Charting in an EHR consists of clicking boxes, do you feel this provides enough detail about
the patient, condition, and events if there was a lawsuit?
The EHR charting system has many different formats of charting. Some areas within the HER have quick charting where you can click boxes to answer certain questions related to the patient’s history or from other gathered information
(Ommaya et al., 2018)
. Yes, I feel that clicking the boxes provides the main and broad history of the patient and more can be added at
the bottom in the “other” section. If a patient feels that he or she was not provided the best care while in the hospital or given wrong information, they have the right to act to the court system. The information that was documented in the charting boxes can be used as evidence. For example, if the patient was given a wrong diagnosis or wrong information regarding their diagnosis that’s a form of negligence. Because the health provider was misinformative of giving
the right information or right diagnosis the correct patient data can be found in the information
boxes on the electronic health records system obtain by the provider or nurse. This information
can be used to the advantage of the patient to sue the hospital for incorrect information and treatment provided to the patient.
Data being tracked by organizations.
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Introduction to Theory in Healthcare Informatics
Data is any information such as facts and numbers that are used to analyze or make decisions. There are many different forms of data and can be used in everywhere in the world. Health data is the process of analyzing, collecting, and then using the information for patient resources and documentation. With the EHRs patient data is immediately available system wide. Research is the major reason why data is collected; its analysis and interpretation paves way for understanding a certain area of interest and forms the basis for decision making. Better results can be achieved, and better decisions made by ensuring that accurate data is collected and analyzed well. According to Hebda, Hunter, and Czar (2019) there are three types of data tracked
by organizations which are descriptive, predictive, and prescriptive data (Heeda, T., Hunter, K., & Czar,2019). The health industry has different organizations as well that track data such as the Consumer
Assessment of Healthcare Providers and Systems. This organization gathers information concerning the patients views on healthcare services that they have received while attending a healthcare facility. Consumers of health services then uses this information to make comparisons and contrasts between other healthcare providers (Heeda, T., Hunter, K., & Czar,2019). The goal with gathering this information is to improve the quality of services given to patients. Patient falls is another critical data that is collected throughout every hospital. Patient falls may be defined as intentional or unintentional falling of patients which may not or may result in any type of injury. National Database of Nursing Quality Indicators (NDNQI) is the organization that this data is reported too. Health facilities are also required to reduce patient readmission rates within a 30-day window. For this reason, hospitals are given financial incentives in what is called the hospital readmission reduction program. Organizations, therefore, collect information on patients with conditions such as chronic obstructive pulmonary diseases, diabetes, and heart failure among others (Heeda, T., Hunter, K., & Czar,2019). This information is then used by the organizations in formulating ways of improving outcomes. In my opinion there are 6
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no ethical concerns in collecting any of this data because no patient personal information is being shared. There are no names or identifying factors. When the information is submitted to these organizations, it only contains the data collected and any intervention that had to be implemented to improve the compliance and prevent reoccurrence.
Based on input from the discussion forum, describe your selected topic. How does your project relate to this class, and why is it important to you?
For my signature assignment I chose how informatics reduces medication errors, prevents harm to patients, and enhances patient safety. Another broad topic that I would be interested in researching relates to telehealth services. After the pandemic experience, the world went through, telehealth became more popular and prominent in all healthcare facilities. As a registered nurse working in the setting of Med/surg and ICU I use EHR, telehealth, etc. daily
and they have a major impact on my day-to-day operations. Conclusion
After the pandemic that the world just faced informatics has become a major key component of healthcare. EHR is the brain of documentation of the patient’s health and medical history. EHR is also organized and analyzes data and information found in the records and information collected for the patient. Nurse and patient communication and interaction while recording accurate information should be balanced
. Data collection is an important part 7
Introduction to Theory in Healthcare Informatics
of informatics. The goal is gathered and review information and make positive outcomes to improve the healthcare system.
Topaz, M. (2019).
References
Heeda, T., Hunter, K., & Czar, P. (2019). Handbook of Informatics for Nurses and Healthcare Professionals
(6th ed.). Pearson. Hoover, R. (2017). Benefits of using an electronic health record. Nursing
Critical Care
, 12
(1), 9–10. https://doi.org/10.1097/01.ccn.0000508631.93151.8d
McDonald, Ewan W., et al. “E-Learning and Nursing Assessment Skills and Knowledge – an Integrative Review.” Nurse Education Today
, vol. 66, July 2018, pp. 166–174., https://doi.org/10.1016/j.nedt.2018.03.011. Ommaya, A. K., Cipriano, P. F., Hoyt, D. B., Horvath, K. A., Tang, P., Paz, H. L., DeFrancesco, M. S., Hingle, S. T., Butler, S., & Sinsky, C. A. (2018). Care-centered clinical documentation in the digital environment: Solutions to alleviate burnout. NAM Perspectives
, 8
(1). https://doi.org/10.31478/201801c
Rohwer, A., Motaze, N. V., Rehfuess, E., & Young, T. (2017, March 2). Informatics of evidence based health care (EBHC) to increase EBHC competencies in healthcare professionals: A systematic review. Wiley Online Library. Topaz, M. (2019). Informatics Theory and Practice. In Handbook of Informatics for Nurses and Healthcare Professionals (Sixth , pp. 20–41), Pearson. 8
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