Electronic Documentation, Health Record Pratice And Health Research (A Case Study Of Fmc Asaba)

Description

ABSTRACT

Electronic documentation, health records and health research offer a valuable resource to improve health surveillance and evaluation as well as informing clinical decision making. They have been introduced in many different settings, including low- and middle-income countries, yet little is known of the progress and effectiveness of similar information systems within FMC Asaba. This study examines the implementation of Electronic documentation, health records and health research systems for use at a population health level in FMC Asaba, in Delta state, Nigeria and to identify their current role within public health, key success factors, and potential barriers in implementation. A systematic search process was implemented. Five databases were searched with MeSH key terms and Boolean phrases. Articles selected for this review were based on hospital provider electronic records with a component of implementation, utilisation, or evaluation for health systems or at least beyond direct patient care. A proposed analytic framework considered three interactive components: the content, the process, and the context. In this work, Thirty-two articles were included in the review. Evidence suggests that benefits are significant but identifying and addressing potential challenges are critical for success. A comprehensive preparation process is necessary to implement an effective and flexible system. Electronic documentation, health records and health research implemented for public health can allow the identification of disease patterns, seasonality, and global trends as well as risks to vulnerable populations. Addressing implementation challenges will facilitate the development and efficacy of public health initiatives in FMC Asaba to identify current health needs and mitigate future risks.

Abbreviations

EHR:	Electronic health record
ICT:	Information and communication technology
HIC:	High-income country
LMIC:	Low- and middle-income country.

 

TABLE OF CONTENTS

COVER PAGE

TITLE PAGE

APPROVAL PAGE

DEDICATION

ACKNOWELDGEMENT

ABSTRACT

CHAPTER ONE

1.0      INTRODUCTION

1.1      BACKGROUND OF THE STUDY

• PROBLEM STATEMENT
• AIM OF THE STUDY
• OBJECTIVE OF THE STUDY
• SIGNIFICANCE OF THE STUDY
• PURPOSE OF THE STUDY
• LIMITATION OF THE STUDY
• BENEFIT OF THE STUDY
• RESEARCH QUESTION
• DEFINITION OF TERMS

CHAPTER TWO

LITERATURE REVIEW

• OVERVIEW OF THE STUDY
• DEFINITION OF THE STUDY
• HISTORY OF ELECTRONIC HEALTH RECORDS
• CLINICAL AND ADMINISTRATIVE NEED FOR AN HER
• ELECTRONIC HEALTH RECORDS APPLICATIONS REVIEW
• REVIEW OF HEALTHCARE EHR STANDARDS
• REVIEW OF EHR SOFTWARE
• HARDWARE AND NETWORKING

CHAPTER THREE

3.0      RESEARCH METHODOLOGY

• INTRODUCTION
• ETHICAL APPROVAL
• STUDY AREA
• RESEACH DESIGN
• ANALYTICAL FRAMEWORK
• SEARCH STRATEGY
• SEARCH OUTCOMES

CHAPTER FOUR

4.0      RESULT AND DISCUSSION

4.1      RESULT

4.2      DISCUSSION

CHAPTER FIVE

• CONCLUSION
• RECOMMENDATION AND FUTURE WORK
• REFERENCES

CHAPTER ONE

1.0                                          INTRODUCTION

1.1                            BACKGROUND OF THE STUDY

Electronic documentation, Health Records and health research are collectively called Electronic Medical Records (EMR’s).The implementation of Electronic documentation, health records and health research in medical practice has seen a significant increase in recent years. Electronic documentation, health records and health research systems present a valuable opportunity to improve health surveillance and evaluate service provision potentially leading to improvements in the management and the promotion of public health [1]. Findings suggest that most clinicians use the information available to examine the overall condition of the patient and inform clinical decision making and for shared communication across patient care teams [2]. By June 2013, three-quarters of office-based physicians in the United States had incorporated Electronic documentation, health records and health research into their practices [3]. The purchase and implementation of Electronic documentation, health records and health research systems are a significant investment of resources but the effectiveness of the approach also depends on the physicians’ willingness to adopt the new technology into everyday practices [4].

Primary clinical care and population health have complementary goals of improving the health of patients and communities but seldom create effective partnerships to increase the wellness of both the patient and populations [5–7]. Changing healthcare goals require flexible systems. In the current financial climate, it may be argued that population health requires the proactive application of strategies and interventions to defined groups of individuals to improve the health of those individuals at the lowest cost [8]. Researchers have been using Electronic documentation, health records and health research systems to gather rich data in areas such as heart disease, smoking, and the delivery of preventative services [9, 10]. Electronic documentation, health records and health research have allowed for the tracking and consolidation of vaccination programmes, enabling improved design and sustainability of effective immunisation strategies [11]. For most healthcare providers, Electronic documentation, health records and health research provide easy access to patient information, and although the value of Electronic documentation, health records and health research in clinical settings is not to be underestimated, the technological requirements for health information are ever-changing [12]. For example, in the United States, the introduction of the Patient Protection and Affordable Care Act (ACA) was predicted to radically change the functions of health departments, requiring new developments in health technology in an effort to track those changes and potentially creating competitive pressures [13]. Data sharing—in keeping pace with policy changes—brings a new level of complexity. A recent international comparative study of the use of Electronic documentation, health records and health research for research found that the procedures for information governance, levels of adoption, and required time and ease of obtaining consent varied significantly across the countries [14]. Existing systems for collecting and analysing data frequently lack coordination and effective interconnectedness within the departmental and hospital systems, creating challenges in the analysis and interpretation of patient outcomes, particularly as it pertains to a specific population or community [15–17]. The ability to provide effective and preventative care management will require a more sophisticated and expansive level of data collection on selected populations that currently outstrips the capacity of most healthcare organizations [18].

However, the gap between medical demands and supply also varies significantly between high- and low- and middle-income countries (HIC; LMIC) [17]. The challenge facing public health practitioners is that as Electronic documentation, health records and health research systems progress, the gap between high- and low- and middle-income countries widens, increasing the risk that the most vulnerable populations are left further behind in the provision of effective healthcare and public health strategies. While developed countries such as the United States and United Kingdom have led the way in the implementation of Electronic documentation, health records and health research, less is known of the progress and effectiveness of similar information systems within FMC Asaba, Delta state Nigeria. Understanding the progress that has been made and the processes by which Electronic documentation, health records and health research is adapted to different settings in FMC Asaba allows practitioners an opportunity to learn valuable lessons and implement effective systems to promote and improve individual and community health.

Therefore, this review examines the implementation of Electronic documentation, health records and health research systems for use at a population health level in FMC Asaba and to identify their current role within public health, key success factors, and potential barriers in implementation.

1.2                                   PROBLEM STATEMENT

The increased transparency, portability, and accessibility acquired by the adoption of electronic medical records may increase the ease with which they can be accessed by healthcare professionals, but also can increase the amount of stolen information by unauthorized persons or unscrupulous users versus paper medical records, as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act and by large-scale breaches in confidential records reported by Electronic documentation, health records and health research users.[Griffin Hospital reports, 2010] Concerns about security contribute to the resistance shown to their adoption.

Handwritten paper medical records may be poorly legible, which can contribute to medical errors. According to Institute of Medicine (1999), Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. Electronic records may help with the standardization of forms, terminology and data input. [Electronic Health Record Error Prevention, 2015] Digitization of forms facilitates the collection of data for epidemiology and clinical studies.[ Health Information Exchanges, 2011] However, standardization may create challenges for local practice. Overall, those with EMRs, that have automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.[ Clinical Information Technologies, 2009]

Electronic documentation, health records and health research can be continuously updated. If the ability to exchange records between different Electronic documentation, health records and health research systems were perfected, it would facilitate the coordination of health care delivery in non-affiliated health care facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management, and public health communicable disease surveillance. However, it is difficult to remove data from its context.[ Greenhalgh T, 2009]

1.3                                    AIM OF THE PROJECT

The main aim of this study is to digitalize the health information and research for improving efficiency, quality of care and it defiantly reduces the costs. In other words, this study discusses how clinical information or document are recorded, stored, and accessed on a network which may include multiple medical providers

1.4                              OBJECTIVES OF THE STUDY

At the end of this work the following objectives shall be able to achieved, that is, to be able to keep:

• Patient Demographics
• Progress Notes
• Current/Past Medications
• Medical History
• Laboratory Data/Radiology Reports
• An electronic documentation, health records and health research has the ability to share automatically share and update information among different offices and organizations
• Through Electronic documentation, health records and health research systems standardization of medical health service is possible.

1.5                                  PURPOSE OF THE STUDY

The purposes of this work are:

1. To improve quality, safety and efficiency & reduces costs
2. With this Systems, physician and health practitioner improves care coordination.

1.6                                                   SCOPE OF THE STUDY

Electronic documentation, health records and health research are electronic versions of patients’ healthcare records. An electronic health record gathers, creates, and stores the health record electronically. The electronic health record has been slow to be adopted by healthcare providers. The federal government has recently passed legislation requiring the use of electronic records or face monetary penalties.

1.7                                           SIGNIFICANCE OF THE STUDY

This study will improve clinical documentation, quality, healthcare utilization tracking, billing and coding, and make health records portable. The core components of an electronic health record include administrative functions, computerized physician order entry, lab systems, radiology systems, pharmacy systems, and clinical documentation. HL7 is the standard communication protocol technology that an electronic health record utilizes. Implementation of software, hardware, and IT networks are important for a successful electronic health record project.

1.8                                                 BENEFIT OF THE STUDY

The benefits of an electronic documentation, health records and health research include a gain in healthcare efficiencies, large gains in quality and safety, and lower healthcare costs for consumers. This system challenges include costly software packages, system security, patient confidentiality, and unknown future government regulations. Future technologies for electronic health records include bar coding, radio-frequency identification, and speech recognition.

1.9                                                   RESEARCH QUESTION

At the end of this study student involved shall be able to answer these questions:

1. What is the definition of an Electronic documentation, health records and health research?
2. How does an Electronic documentation, health records and health research differ from the paper record?

• What are the functional components of an Electronic documentation, health records and health research?

1. What are the benefits of an Electronic documentation, health records and health research?
2. What are the impediments to development and use of an Electronic documentation, health records and health research?

1.10                                           LIMITATION OF THE STUDY

With all the benefits that Electronic documentation, health records and health research’s bring to healthcare, there remain some challenges that must be addressed and overcome. The first challenge of an Electronic documentation, health records and health research is the immense cost of electronic documentation, health records and health research systems (Gordon, 2012).  Electronic documentation, health records and health research systems  in large hospitals can run into the $15 million to $30 million range (Hufford, 1999). If a small hospital is not  aligned with a larger hospital, the costs can be staggering and eat up a whole year’s capital budget (Gordon, 2012).

The second challenge is, depending on the Electronic documentation, health records and health research system chosen, the Electronic documentation, health records and health research can lead to increased clinician documentation time. Some physicians and nurses are going to be resistant to change and will want to revert back to the old paper based systems (Hufford, 1999). Failure to change clinical processes while implementing an electronic documentation, health records and health research can ruin any efficiency hoped to be gained by the investment.

Other challenges Electronic documentation, health records and health research system face include slow systems, either due to the software or to poor networking speeds, and system crashes that will stop all clinicians from being able to perform their work. Backup and redundancy systems have to be developed.

Electronic documentation, health records and health research system security is a large challenge that has to be addressed. Electronic medical records could  become a huge target for hackers as medical records are rich in personal information (Featherly, 2011). Medical identity theft is becoming a bigger problem and the introduction of electronic documentation, health records and health research’s will perpetuate this issue (Featherly, 2011). An electronic documentation, health records and health research security and patient confidentiality are also covered under HIPAA rules and regulations and a whole host of precautions must be under taken to meet these privacy and security laws.

The last major challenge, for electronic documentation, health records and health research’s is the ability to meet the government’s meaningful use rules. The meaningful use rules are substantial (Ford, Menachemi, Huerta, Yu, 2010). Stage one meaningful use rules include fourteen core requirements and a choice of five of ten optional measures (Jarousse, 2010). Stage two and stage three meaningful use rules have yet to be published by the federal government. This poses a huge unknown risk for healthcare providers because failure to meet the meaningful use criteria will result in reduced Medicare and Medicaid payments.

1.11                                               DEFINITION OF TERMS

The following is a list of basic terms you will need to know as you study this work:

• Certification – This relates to a national effort to “certify” various requirements for EHR software. The Certification Commitee for Health Information Technology (CCHIT) is tasked with determining what basic “must have” features EHR systems contain in order to be “certified.”
• Electronic Health Record (EHR) – This term refers to computer software that physicians use to track all aspects of patient care. Typically this broader term also encompasses the practice management functions of billing, scheduling, etc.
• Electronic Medical Record (EMR) – This is an older term that is still widely used. It has typically come to mean the actual clinical functions of the software such as drug interaction checking, allergy checking, encounter documentation, and more.
• Integrated EHR – This refers to an electronic documentation, health records and health research that is integrated with practice management software. Typical choices include purchasing a fully integrated product which performs all the functions of practice management software, or a stand-alone electronic documentation, health records and health research which is compatible with an existing practice management system.
• Structured and unstructured data entry – There are several ways of entering data into your electronic documentation, health records and health research as you practice. These include dictating straight into the software (voice recognition), templates, and writing (handwriting recognition).
• Templates – Pre-structured portions of the software for common and/or basic visits. These templates fill in a standard set of data which you may then customize for each individual visit. Templates can be used with dictation, writing, or choosing among a menu of options formulated for each specific template.