Key Institutional Variables in Health Facility IT System Implementation

Medical records, medical charts, and health records are all phrases that are sometimes used interchangeably. They define the systematic documentation of self-reported patient information as well as the notes on diagnoses, care, and treatment made by the nurse, caregiver, or physician. These records have long been important tools that serve as a doorway through which medical professionals may readily step into a patient's history to not only understand prior care, current status, and diagnosis, but also construct a treatment plan.

Until recently, however, such recording was done on paper. Because of this structure, patient records were more prone to omissions, loss, and inaccuracies. Thankfully though, medical charts have entered the digital edge. The technological advances have resulted in thorough databases with minimum human error quotient. As a matter of fact, how can one be able to know where they are going if they cannot tell where they have been? This is particularly true in relation to keeping of accurate medical records that result in improved patient outcomes. Too often, their lives depend on it. Without thorough methodical documentation of their biographical data, symptoms, diagnoses and treatments, the subsequent physician who treats the patient will have a hard time providing the best care possible (Amatayakul & American Health Information Management Association. 2012).

As well as ensuring proper patient care, accurate electronic records can act as protection to a medical doctor, nurse or caregiver from any disputes that may emerge concerning treatment, alleged breaches of compliance and lawsuits that may be issued against them. Such clear and readable entries which can be easily be retrieved and made available to the patient upon request will help cushion a practitioner from any potential breaches of privacy laws.
Nevertheless, the use of data-driven health records in the profession of medicine and malpractice provides the chance for the office to enhance its oversight while lowering liability. This makes it possible to take the practice to a higher atmosphere of safety and effectiveness without compromising the human touch and personalization art of the medical field (Amatayakul & American Health Information Management Association. 2012).

One undeniable fact is that there will always be people visiting the doctor. In spite of the reason for the visit, a report that becomes a permanent element of their medical record will need to be written and electronically recorded. As far as this task is concerned, we anticipate major developments in medical transcriptions of such data. The role will no longer be solely transcribing, but also edit voice recognition draft reports as well as proofread the reports. These changes will be fueled by industry trends that will no doubt proceed to shape the role of medical transcription. A possible trend is the advancement in voice recognition software where instead of a doctor dictating a report to transcriptions, they will directly do so to sophisticated software on computers. This will be vital since it will be faster and easier for doctors who have no time to edit and proofread reports (Doonan, 2013).

Another trend is the giving of extra attention to security issues surrounding patient stored details. Medical transcriptions are known to be privy to confidential information, and security will be enhanced. Despite the technological advances and major trends expected in the near future, it is vital to note that only a fraction of doctors use electronic patient records. Many physicians particularly in small practices have remained skeptical in implementing them. Why they are not convinced to adopt these wondrous information systems?

Some physicians argue that the systems are not safe. So many companies making separation of the good from the bad to be a heavy chore sell them. The medical systems can easily be misused or hacked. When such unauthorized access is made, the privacy of the information stored is invaded, sensitive details are revealed and the security of the doctors and patients alike is threatened.

In addition, the cost of purchase and maintenance is significantly high. It is not only the thousands of dollars charged to install an electronic records system but also the prohibitive expense of hiring staff to manage the data, maintain the systems as well as comply with the new rules and regulations. Nonetheless, these bureaucratic practices demand an efficient strategy for monitoring, tracking, controlling and dictating practice activities. They actually require total reorganization of practices (Doonan, 2013).

A number of doctors also feel that such records are inefficient. For instance, one ophthalmologist says that when he receives an electronic medical summary, he ignores it: “It does not tell me the patient’s story. It does not tell me why the patient is here, what troubles the patient, and what the referring doctor wants me to do.” No matter how systematically assembled or gathered the information is it is not narrative. Instead, it is actually a distraction from patient time.  

In order to enhance the handling of confidential patient information, the Health Insurance Portability and Accountability Act (HIPAA) went into effect in April 2003. With the ultimate objective of protecting not only the inappropriate disclosure of private medical information but also ensuring patients have the right to be made known of the contents of their medical records, HIPAA affects every avenue of health care. For instance, computers must be protected by the use of passwords and not easily seen from public view. Sign-in sheets in hospitals do not ask for the reason of the visit anymore. Unless it is for treatment or business purpose, healthcare workers are prohibited from discussing details that may in any way reveal a patient’s identity. With this legislation, the patient’s rights are better taken care of by federal law as compared to the patchwork of state regulations (Sittig, 2014).

In order to stimulate the adoption of electronic health recording systems, the Health Information Technology for Economic and Clinical Health Act (HITECH) was constructed. One of the most fundamental features of this initiative was the adoption of a series of computerized systems and applications that made it unnecessary and obsolete to issue verbal and written requests. Pharmacies are now capable of receiving and dispensing medication with the aid of scripts, which can be sent and received in a matter of seconds.

In spite of this increased speed of operations and enhanced accuracy of transmitted information, the HITECH Act is in no shortage of disadvantages. A significant setback is associated with the implications for all medical organizations that are reluctant to health clinical information system as mandated by the Act. These medical practitioners in effect deny themselves the economic stimulus payments as well as their future reimbursement rates for their Medicare patients. According to Sittig (2014), “HITECH doesn’t mandate that anyone participate in the incentives. But it includes what could be a powerful “threat.” Those physicians’ offices and hospitals that have not made “meaningful use” of records systems by the end of 2014 will see a series of escalating cuts in their reimbursements for treating Medicare patients starting in 2015”.  In order to cushion themselves against such negative effects that could deeply cut their revenues, they should promptly take the needed measures so as to benefit from the available incentives.

How have these federal initiatives affected the standards of health care information for patient privacy, safety, and confidentially? As outlined above, privacy addresses the issue of who has access to personal information and under what specified conditions. Confidentiality on the other hand ensures that the gathered information is safeguarded in the context of an intimate relationship. It, for example, prevents medical practitioners from disclosing information shared with them by a patient. Technical and procedural safety measures as a result have also been implemented in order to prevent unauthorized access, use, modification and dissemination of stored data. More effective communication between the patient and the physician has been promoted since fewer patients are reluctant to disclose complete, personal and sensitive information. Privacy has assisted in establishing more intimate relationships and at the same time maintaining a variety of social relationships. This has been made possible since patients have the ability to decide who will know what about them and has access to them.

In a wider scope, enhanced confidentiality and privacy has resulted in fostering socially beneficial undertakings like health research. Members of the society are ready and willing to take part in such researches since they believe that their privacy is protected. To adolescents, confidentiality is of much importance if they are expected to be frank and open especially on matters of reproductive health or substance abuse (Sittig, 2014).

We must never forget, though, that the most important resource in any organization is the human resource. In addition to acquisition and proper adoption of information systems, there are a number of workforce processes within the healthcare entities that need to be properly reviewed. One of them is the attraction of the right employees by sourcing, interviewing, hiring and training new employees. If you have the wrong employees, it doesn’t matter whether you find the right direction; you definitely won’t make a great organization. Another process involves retaining the existing employees through managing, training, engaging and developing them. The supervisors need to pay more than ordinary attention to the needs of healthcare professionals in order to create and maintain a positive working environment. Transitioning of employees is another process that entails expanding their responsibilities as well as planning for their transfer. This will provide opportunities for advancement (Sittig, 2014).

A significant process that the organizations need to seek ways to completely eliminate is employee turnover. The annual turnover rate at the moment in healthcare organizations is startling. According to the Human Resource Management Association, nearly one in every five employees (20.4 percent) quit their jobs annually. It costs the organization over $50,000 to both recruit and train a new nurse. The cost of replacing an experienced Critical Care nurse can be as much as $120,000. This can be mitigated when there is a high level of job security and satisfaction among staff.

No doubt, a lot of pressure on hospitals, clinics, physicians, systems and other medical providers to be digitized is profound. The need to improve the positive workforce processes while eliminating the less useful has never been greater. With enhanced medical recording systems and embraced digital data storage and retrieval processes, the medical practitioners will experience a more efficient and attractive working environment as they strive to keep our health in check (Doonan, 2013).

References

Amatayakul, M., & American Health Information Management Association. (2012). Electronic health records: A practical guide for professionals and organizations.

Doonan, M. (2013). American federalism in practice: The formulation and implementation of contemporary health policy.

Sittig, D. F. (2014). Electronic health records: Challenges in design and implementation.