Electronic Medical RecordsAlissa Bergstresser

Objectives

✤ Describe Electronic Medical Records

✤ Discuss current software utilized with Electronic Medical Records

✤ Assess the role of the nurse when working with this Electronic Medical Records

✤ Advantages/Disadvantages

✤ Examine related legal/ethical issues

Electronic Medical Records

✤ Electronic compilation of care provided in in- and out-patient settings

✤ Computerized program that streamlines patient care

✤ Instantaneous retrieval of information

✤ Patient information and diagnosis

✤ Test results

✤ Doctor’s orders

✤ Allows for data entry at the time of care

Statistics

✤ In 2006, 29.2% of physicians reported using full or partial EMR systems in their office-based practices

✤ 22% increase since 2005

✤ 60% increase since 2001

✤ (Hing, Burt, & Woolard, 2007)

✤ As of 2009, only 2% of US hospitals utilized fully functional Electronic Medical Records

✤ (Steenhuysen, 2009)

Hardware

✤ Server

✤ Provides interface between all computers in the network

✤ Workstations

✤ Allow for individual users to access and input information

✤ Computers, computers on wheels, laptops, PDA’s

✤ External memory/storage

✤ Depending on size of the facility

Servers

✤ Defined

✤ (ser´ver) (n.) A computer or device on a network that manages network resources. (Webopedia, 2010)

✤ Extremely important for reliability and performance

✤ Need varies with type and size of institution

✤ Existing servers can be adapted to accommodate new software

Examples of Currently Used Software

✤ Cerner - PowerWorks Electronic Medical Records

✤ Supports 30 different specialities

✤ Provides patient education within the same program

✤ 3M - Chartview

✤ Rated in the top 100 programs by Healthcare Informatics

✤ Easy-to-use features compatible with Windows XP

✤ GE Healthcare - Centricity Advance

✤ Designed for doctor’s offices

✤ Completely web-based - allows for ease of updates

Cerner PowerWorks✤ Currently serving 6,000 clients

✤ Serves

✤ Allows for remote access

✤ Easily generates Physician Quality Reporting Initiative reports

✤ Claims financial savings compared to paper charting

✤ $30,000/physician/year

✤ $1/record/year

“health organizations ranging from single-doctor practices to entire countries..” (Cerner, 2010).

PowerWorks Usability✤ Early, central focus on users

✤ Cerner works with facilities to implement specific programs

✤ Iterative designs

✤ Provides data sharing and connectivity to each facility

✤ Empirical usability measures

✤ 58 % quality improvement in 2007

✤ Quality plan initiated in 2008

✤ 34% reduction in defects

Nursing and Electronic Medical Records

✤ Role of the Nurse

✤ Data entry

✤ Data retrieval

✤ Doctor’s orders

Nursing and Electronic Medical Records

✤ Advantages

✤ Time saver

✤ All information in one place

✤ Real-time charting

✤ Disadvantages

✤ New skill/program to learn

✤ Time consuming

✤ Downtime

Competency and Informatics Nurses

✤ Competency

✤ Initial trainings offered prior to program launch

✤ Often, little time is devoted to proper training

✤ No global requirement for EMR training

✤ No global measurement of employees’ competence

Competency and Informatics Nurses

✤ Informatics Nurses

✤ Work with software company

✤ Individualize program for each facility

✤ Provide initial training sessions

✤ Super users

✤ Continuous adaptations

✤ Support

Ethical/Legal Implications

✤ Confidentiality

✤ Licensing

✤ Inappropriate Access

✤ User ID/Password

Information System Review

✤ Electronic medical records

✤ Clinical documentation system

✤ Used by

✤ Nurses and physicians

✤ Ancillary staff

✤ Radiology, secretaries, lab personnel

Information System Review

✤ Utilization

✤ Individuals utilize EMR’s for:

✤ Documentation

✤ Medical records

✤ Order entry

✤ Configuration

✤ Mainframe

✤ Local Area Network

✤ Workstations

Information System Review

✤ Data Standards

✤ American National Standards Institute

✤ Health Level 7

✤ International Standards Organization

✤ Workgroup for Electronic Data Exchange

Recommendation

✤ Highly recommended

✤ Cost Efficient

✤ One program, vast information

✤ Time Efficient

Summary

✤ Electronic compilation of care provided in in- and out-patient settings

✤ Computerized program that streamlines patient care

✤ Instantaneous retrieval of information

✤ Used by

✤ Nurses and physicians

✤ Ancillary staff

✤ Time and money saver

References

3M. (2010). Chartview Software for Electronic Medical Record Viewing. Retrieved September 15, 2010, from http://solutions.3m.com/wps/portal/3M/en_US 3M_Health_Information_Systems/HIS/Products/ChartView/.

American Medical Association. (2010). Patient Physician Relationship Topics. Retrieved September 14, 2010, from http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician relationship-topics/patient-confidentiality.shtml.

Cerner PowerWorks. (2010). Electronic Medical Record (EMR). Retrieved September 15, 2010 from, http://www.cerner.com/public/Cerner_3_asp?id=32227.

Garets, D., & Davis, M. (2006). Electronic Medical Records vs. Electronic Health Records: Yes, There Is a Difference. HMMS Analytics Database. Retrieved from www.himssanalytics.org.

GE Healthcare. (2010). Centricity Advance. Retrieved September 16, 2010, from https://www2.gehealthcare.com/portal/site/usen/gehchome/.

References Cont.

Hing, E.S., Burt, C.W., & Woodwll, D.A. (2007). Electronic Medical Records Use by Office-Based Physicians and Their Practices: United States, 2006. Advance Data From Vital Health Statistics. Number 293. Retrieved from http://www.cdc.gov/nchs/data/ad/ad393.pdf.

Open Clinical. (2010). Electronic Medical Records. Retrieved September 14, 2010, from http://www.openclinical.org/emr.html.

Steenhuysen, J. (2009). Few U.S. hospitals have electronic medical records. Reuters. Retrieved from http://www.reuters.com/articleidUSTRE52O6WO20090325.

Webopedia. (2010). Server. Retrieved October 7, 2007 from http://www.webopedia.com/TERM/S/server.html.