FOUR PRIMARY FUNCTIONS 1. THE BACKBONE OR PRIMARY SYSTEM USED TO INTEGRATE WITH THE VARIOUS APPLICATIONS THROUGHOUT THE ORGANIZATION. 2. MANAGE THE ADT (ADMISSION, DISCHARGE AND TRANSFER) PROCESS 3. COMMUNICATE INFORMATION BETWEEN THE CLINICAL UNITS AND THE VARIOUS HOSPITAL DEPARTMENTS. 4. USED TO PRODUCE A NUMBER OF REPORTS THAT SUPPORT THE DAILY OPERATIONS OF THE INSTITUTION.
CLINICAL INFORMATION SYSTEM
CONSISTS OF A LARGE GROUP OF AUTOMATED SYSTEMS THAT PROCESS PATIENT DATA TO SUPPORT PATIENT CARE FUNCTIONS: COLLECTING PATIENT ASSESSMENT AND HEALTH STATUS DATA DEVELOPING HEALTH CARE PLANS MANAGING THE ORDER ENTRY PROCESS KEEPING MEDICATION ADMINISTRATION RECORDS, DEVELOPING WORK LISTS, AND PRODUCING REPORTS SUCH AS PATIENT PROBLEM LISTS.
TYPES OF CLINICAL INFORMATION SYSTEM :
DOCUMENTATION SYSTEMS DEPARTMENTAL SYSTEMS
TYPES OF CLINICAL INFORMATION SYSTEM :
DOCUMENTATION SYSTEMS USED FOR THE DEVELOPMENT OF PLANS OF CARE, DOCUMENTATION OF PATIENT DATA AND ACCESS TO CLINICAL INFORMATION DECREASING THE TIME USED TO DOCUMENT CARE WHILE INCREASING THE QUALITY OF THE DOCUMENTATION AND INCREASING DATA ACCESS TO CLIENT DATA
TYPES OF CLINICAL INFORMATION SYSTEM :
DEPARTMENTAL SYSTEMS SUPPORT THE DAILY WORK OR OPERATIONS OF A CLINICAL DEPARTMENT ACCEPT PATIENT ORDERS, SCHEDULE PATIENTS, EQUIPMENT AND ROOMS, PRINT LABELS AND WORK LISTS AND MAINTAIN INVENTORIES IMPROVED EFFICIENCY OF THE DEPARTMENT
FOUR DOMAINS:
CLINICAL PRACTICE ADMINISTRATION EDUCATION RESEARCH CLINICAL PRACTICE
PROVIDE AUTOMATED SUPPORT TO THE NURSING PROCESS. USED TO COLLECT AND RECORD PATIENT DATA FOR ASSESSMENT OR MONITORING PURPOSES, TO DEVELOP PLANS OF CARE, TO PRINT REMINDERS AND WORK LISTS, TO DOCUMENT CARE, AND TO IDENTIFY GOAL ACHIEVEMENT. ADMINISTRATION SUPPORT THE ADMINISTRATIVE ROLE AND USUALLY DEAL WITH THE DAY-TO-DAY OPERATION OF THE CLINICAL OR NURSING SERVICE DEPARTMENT
EDUCATION
SUPPORT NURSING EDUCATION AND ARE USED IN TEACHING AS WELL AS IN MANAGING THE EDUCATIONAL PROCESS RESEARCH CONSISTS OF A VARIETY OF DIFFERENT GENERIC COMPUTING PROGRAMS. IT IS NOW POSSIBLE TO COLLECT DATA FROM AN AUTOMATED DATABASE IN SECONDS, WHEREAS IT WOULD HAVE REQUIRED MONTHS OF SEARCHING IF THE SAME DATA WERE STORED IN PAPER RECORDS. Standard Areas of NURSING: Nursing P ractice Nursing E ducation Nursing R esearch Nursing Administration
COMPUTERS IN NURSING EDUCATIONS COMPUTER Assisted Education PDA (Personal Digital Assistants) LCD Projectors Wireless Routers Desktops Laptops Smartphone VIDEOS/ANIMATIONS Distance learning Testing (NCLEX) Student and course record management COMPUTERS IN NURSING PRACTICE Functions Records client information Provides access to other departments Used to manage client scheduling DOCUMENTAION OF CLIENT STATUS AND MEDICAL RECORDS KEEPING Provides access to standardized forms, policies and procedures Access data about client that may be somewhere in the medical record or elsewhere in health care agency.
BEDSIDE DATA ENTRY records clients assessments, medication administration, progress notes, care plan updating, client acuity and accrued charges
COMPUTER BASED CLIENT RECORD EMRs/CPRs Provides easy retrieval of specific data such as trends in vital signs, immunization records, current problems It can be designed to work providers about conflicting medications or client parameters that indicate dangerous conditions
ELECTRONIC ACCESS TO CLIENTS Used extensively in health care to assess and monitor clients conditions Data accumulated from various electronic devices are stored for research purposes Can monitor client Computerized diagnosis Telemedicine
PRACTICE MANAGEMENT Used to order supplies, tests, meals, and services, from other departments Allows nursing service to determine the most costly items used by a particular nursing unit. May provide information or decisions to modify budget, provide different staffing, move supplies to different locations, or make other changes for more efficient and higher quality care
COMPUTERS IN NURSING PRACTICE A. Human resources All employers must maintain a data a database on each employee Administrators can use this database to communicate with employees, examine staffing patterns, and create budget programs B. Medical records management Allow client records to be searched for trends, number of cases, most expensive cases, and client outcomes. Nurse informaticist can assist administrators with the design and implementation of systems that allow such searches to be generated, analyzed, printed, and distributed.
COMPUTERS IN NURSING PRACTICE C. Facilities management heating, air conditioning, ventilation, alarm systems are computer controlled.
D. Budget and finance claims are transmitted much more quickly Can also effect cost-savings by reducing the desired services time needed for accounts payable and receivables.
COMPUTERS IN RESEARCH
1. Useful in locating current literature about the problem and related concepts Helps in searching for existing documents, and e-mail to colleagues. 2. Software facilitate searches, contains thesauruses so that the most appropriate terms can be selected.
COMPUTERS IN RESEARCH 3. Search literature for instruments that have already been established or to design and test instruments that need to be developed for past study. 4. Helps create form for the collection of data such as informed consent, demographic data, and recording forms. Commonly used software for quantitative data analysis: SPSS ( statistical package for social sciences), SAS ( statistical analysis system), Sys STAT, MYSTAT
5. computer word processing programs are used to author the final reports of research and send research to various readerships. Help speeds completion or research projects
ELECTRONIC HEALTH RECORD ELECTRONIC HEALTH RECORD any information related to the past, present, or future physical/mental health, or condition of an individual. The information resides in electronic system(s) used to capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing healthcare and health related services.. ELECTRONIC HEALTH RECORD Increased patient safety: All information about the patients existing conditions, allergies and drug intolerances is available when Physicians need it, where they need it so that they can make the best decisions for their patients. Increased efficiency: A single source of accurate patient data means Physicians don't need to spend time logging in to different specialist clinical systems or contacting other healthcare institutions for information. ELECTRONIC HEALTH RECORD Trend and data analysis: A central clinical repository of clinical information means that information can be mined and analyzed to contribute to more effective healthcare delivery in the future, and can give a better understanding of trends, patterns and epidemiology in public health.
What is an Electronic Record (EHR)? Other common names computerized patient record (CPR), electronic medical record (EMR) and the electronic patient record (EPR) Part of CIS Resides in a software program providing the health provider an instrument to obtain clinical information and transcribe data into the computer Classified in three groups: (1) Office Based (2) Web-based (3) Handheld or Wireless System
ADVANTAGES - Instant Access - Legibility - Safer data (protects from loss) - Confidentiality - Flexible Layout - Integration with other info resources - Electronic data - Continuous data processing - Assisted Search - Tailored Paper Output - Always Current!
Clinical DSS focus in EHR for Nurses CPOE Computerized Prescriber Order Entry
BCMA Bar Code Medication Administration Integrated EHR Features Digital Imaging (Laboratory Informatics) Integrated EHR Features Integrated EHR Features Integrated EHR Features Nursing Documentation Integrated EHR Features Nursing Documentation AUTOMATED INFORMATION SYSTEMS IN HEALTH CARE By: Aquia C. Evangelista Subtopics: Administrative System Classification systems Quality Assurance systems Material Management systems Decision Support and Expert System
Administrative System
automate the management of data used in the daily operations of the institution as well a data used for strategic and long range planning. Classification Systems Quality Assurance Systems Material Management Systems
Classification Systems
utilize data to classify patient by the amount and type of care required. Data from classification system can be used to decide the amount of staff to a clinical unit. When classification data are used to make this determination, the classification system is also a staffing system. e.g. second and third degree burns over 605 of the body may require 6 hours of professional nursing time every 8-hour shift. A fifth-day postoperative from open heart surgery may require 2 hours of professional nursing time. Quality Assurance Systems
attempt to measure and report on cost- effective quality care resulting in a high level of patient satisfaction. e.g. patient outcomes or variance reports, performance indicators for providers, infection reports, incident reports, patient satisfaction results, and costing data. These data can be reported for individuals or in aggregate format.
Material Management Systems
for managing supplies and other inventory of an institution. e.g. online catalogue that can be searched, an automatic interface to budget systems, automatic re-ordering of supplies, and alerts that can be issued when there is a significant increase or increase in inventory reports.
Decision Support and Expert System
Decision Support (Automated Decision Support Systems) identify information gaps and taps external knowledge bases. are systems that process information, identifying and demonstrating pertinent relationships. helps in decision-making, but they do not make decisions. e.g. automated scheduling system contains extensive online knowledge base. The system will know several facts about the staff and the institutions staffing rules. The scheduling system will not decide who will work when. aid to a decision maker provides a more complete picture of the interrelations between the information being considered. it is the decision maker who interprets the information and decides what action to take.
Expert Systems
are knowledge-based systems with built-in procedures for determining when and how to use that knowledge.
Wisdom makes it possible for the caregiver to use theories related to death and dying to help a terminal patient express anger and frustration.
Disadvantages of Computer Application in Health Care
high upfront acquisition costs, ongoing maintenance costs, and disruptions to workflows that contribute to temporary losses in productivity that are the result of learning a new system. potential perceived privacy concerns among patients, which are further addressed legislatively in the HITECH Act. Brendon C. Borja R.N.
The Advantages of Computer application in Health Care.
Better staff management
provides an efficient way to handle administrative like workload management, maintaining staff records, scheduling shifts, etc. task accomplished by each nurse can be recorded, and such shift reports can be viewed in a patient- specific manner. aides nurse administrators in assessing staffing requirements, as well as financial management through budgeting and monitoring of expenses.
Improved documentation
Proper clinical documentation is the pillar of every heath care system, and it provides an easy way to record all the necessary data system reduces the need for redundant paperwork and also enables maintaining patient history that can be easily accesses when required.
Efficient decision making
In addition to storing data, certain features of NIS enable information management and decision-making through active and passive systems. Passive systems can organize and formulate the data according to the present parameters, as well as provide parameter specific information, as and when required. Active systems are a step advanced and suggest diagnoses on the basis of predefined criteria applied to the patient information.
Enhance Synchronization
Patient data generated in all the units is always essential for the decision-making in any unit of a medical facility. can be achieved through the integration of NIS with other clinical systems, which enables fast and easy access of the documented information to all the appropriate units.
The Disadvantages of Computer Application in Health Care System
Need for training
nurses need to be trained for the use of various features provided by the system Certain studies have reported that sometimes the nursing personnel find it difficult to understand the design of the system it increases their workload rather than helping them. medical practitioners need to alter some of their practices in order to accommodate the new system.
Long Charting time
The initial time required for creating the record for a new patient may require more than the regular paper-based charts, due to variety of fields that need to be filled.
Difficulty in Customization Clinical systems require a higher degree of customization, not just with respect to the particular health care facility, but also at the level of the patient. Each patient may have a different set of parameters to be considered as vital. Lack of Standardized Vocabulary
Nursing Information System lacks a standardized language for the same time. there is always scope for ambiguity. the terminology available in the system may not match of every user, which causes confusion, making it difficult to use. Disclosure confidentiality The medical records of a patient may become vulnerable to hacking. Patients information is at risk especially if the personnel are sharing passwords and hospital computer codes.
Conclusion
Information systems have greatly influenced management of information in several disciplines of health care, including diagnostics, treatments, nursing as well as palliative care. With their speed and accuracy, Nursing Information System confers several advantages as far as Nursing is concerned. But, there still remain certain drawbacks that need to be tackled in order to improve their efficiency and usability.