Health information is important to every person caring for a person. If pertinent information is missed or not communicated it could be deadly. The Department of Health and Human Services developed a plan to help control this issue. In 2004, federal government, under President Bush, developed a plan for caregivers to make it easier for patients to have access to their health records. The plan was developed to enable patients to have a better say in the healthcare they receive from all caregivers whether it be their family practitioner or hospital systems.
The government has given healthcare providers a timeline to complete the goals set forth in the strategic plan. The plan has two goals patient-focused health care and population health (ONC, 2008, p. 1) Patient focused is to provide higher quality and cost-efficient care through electronic health information (ONC, 2008, p. 1). Population health is about using the health record as a way to be prepared in case of emergency (ONC, 2008, p. 1). Around each goal are four objectives to achieve the plan.
Privacy and security involves exchanging information and still being able to keep the records private by developing policies and procedures to do so (ONC, 2008, p. 2). Interoperability enables movement or exchange of information to support one’s health needs (ONC, 2008, p. 2). Adoption means just a way developing technologies to promote and improve the health records (ONC, 2008, p. 2). Collaborative Governance means to establish ways to continue the use of electronic records and hold people accountable to use them.
The plan lays some great ground work for healthcare providers to use but it is up to the individual companies to hold employees and patients accountable to up hold. The idea is so everyone who comes in contact with the patient knows everything about them to better care for them. Once the plan is in place, it will enable clinicians to share information about the patient with other clinicians through the electronic record system (ONC, 2008, p. 8). The VA has been a leader in electronic records. They use a system called Vista.
This program assists the care provider with information on the patient no matter what hospital they would go to (Scalzi, 2007, p. 26-27)The VA services many patients across the United States and the electronic record system enables clinicians to have access to the records no matter what city the person is in. There are many advantages to electronic records. It enables the patients to know themselves better by giving them the knowledge needed to stay healthy longer. It will help to improve patient to caregiver relationships and provide a safer way of caring for the patients.
By using electronic records it can help cut down on the malpractice cost for physicians. It will provide a better way for patients to have access to and relay information to other healthcare providers. (Endsley, Kibbe, Linares, & Colorafi, 2006, p. 57-62) The hospital I work for is currently in the process of expanding our electronic records. The company is a large system with many hospitals under the name. I have worked for a smaller rural hospital in this system for the last 6 years. We have had electronic discharge instructions for the last 5 years.
On the discharge instructions are: diagnosis including the main histories, test and results preformed, diet, home medications, new medications, follow up appointments, other instructions, and when to call the physician. In October of this year, we started electronic computer charting. It was a culture shock for many of the clinicians. We have a variety of ages in the employees. Some have never used a computer and needed a lot of assistance. This change impacted every department in the hospital.
We still do have a hard chart at this time but in January of next year we will be transitioning into physician order entry and all records will be electronic only. Some of the physicians have voiced the concern over not being able to learn the system and still give their patients the care they need. Many of the nurses explained they felt the same way but learnt to adapt to the situation. By going to physician order entry it will prevent medication errors from poor handwriting and will result in less calls to the physician.
Along with physician order entry, we have revised or invented order sets to have a more uniformed way of admitting patients. Once again come January it will be a long process of training and having great patience with the physicians just as they had for the nurses. We have a few family practitioners using electronic records for patients in the office but they do not have a way for the patient or the hospital to use it. So they give a print out to the patient about the visit having just general information on it. I am not aware of any physicians utilizing a website for patient information yet.
I do not believe my facility is where it needs to be to be complaint with the strategic plan. It just seems like we are making movement slowly. To make the process complete we would need to involve the family practitioner. I am not aware of any such plan. Our hospital rooms all have computers available in the rooms. So it is important to always be aware of who is around you when using the computers and would be able to see private patient information. We also have private and semi-private rooms. It is very difficult to protect privacy in a semi-private room when the other patient is within hearing distance and may have visitors.
Patient confidentiality is a hard thing to protect with the advances of electronic records being used. We are advised to always log off of the computers instead of just minimizing it. The only thing I do not like as a clinician and a consumer is that when the clinicians are charting or inputting information into the computer some of the hands on contact are gone. I just had a follow up with my family physician and her office does use electronic health records and I felt as though she was not in focus with me as a person. She paid more attention to the computer screen and not me.
As a nurse I try hard not to do this. I will explain to my patients what I am doing by using the computer but if I need to talk to the patient I stop typing and walk over to their bed and have eye contact. Nursing is about caring and if you do not make eye contact and touch your patients that will be lost through this transition. The federal government will not change the plan it has in place for electronic medical records. With that being said caregivers need to develop and implement a system that will work for the individual practice and its patients.
Endsley, S. , Kibbe, D. C. , Linares, A. , & Colorafi, K. (2006, May). An Introduction to Personal Health Record. Family Practice Management, 13, 57-62. Retrieved from http://www. aafp. org/fpm/2006/0500/p57. html Scalzi, T. (2007, September). . The VA Leads the Way in Electronic Innovations. Nursing 2007, 37, 26-27. http://dx. doi. org/10. 1097/01. NURSE. 0000287707. 86749. 80 The ONC-Coordinated Federal Health Information Technology Strategic Plan 2008-2012: Using the Power of Information Technology to Transform Health and Care. (2008, June 3). , 1-11