Electronic health record refers to software found in a computer system that aids in patients’ medical records by healthcare providers. Similarly, automated clinical workflows can also be stored in this software. Patients in remote areas can receive treatments with telemedicine sessions where the doctors can prescribe medications electronically. This paper analyses the need for specific guidelines and policies related to an electronic health record tool.
Need for Specific Policies and Guidelines
The chosen situation in a practice setting is the communication between the healthcare givers, supporting staff, and patients using a remotely hosted system. There is a need to follow specific policies and guidelines while using the electronic health record tool. Health care is of a higher standard since doctors begin to use EHRs and set up secure communication channels. This makes it easier for everyone to work since health information is easily transmitted to other stakeholders.
There is easy retrieval of information in case of any reference needed. For instance, in an emergency, EHRs can be recovered. Suppose the victim is in a casualty and cannot describe what happened. In that case, a hospital with a system may be able to communicate with the doctor’s system based on another medical history. The hospital will receive information about your medications, health problems, and tests, allowing them to make informed decisions. Doctors who use electronic health records (EHRs) may find tracking lab results and diagnoses easier or faster. The test does not always need to be repeated because of the results from another doctor. Especially when it comes to x-rays, this reduces exposure to radiation or experiences other side effects from specific lab tests.
Evaluation of the Functioning of the Tool
The set policies and guidelines for electronic health records facilitate the collection and storing of data. The electronic record tool facilitates the storage of data and information about the patient’s medical history. Policy on the access restrictions by third parties limits the flow to ensure that relevant personnel can get the data. Internal communications between the healthcare givers in the various departments make the treatment process smooth and easy.
Evaluation of the Work Setting
Heath care setting refers to the broad categories of services offered in a hospital and specific points in which they are given. These services include outpatient and outpatient, clinical laboratory testing, and consultations with patients. The outpatient services include everyday treatment routines, and patients go home for further healing. Policy governing the use and flow of information ensures that data only circulates within this department for the treatment plan.
Evaluation on how the Tool Supports the Strategic Plan
The strategic plan of any health care organization is to provide quality services to the patients. The electronic health record supports this plan by facilitating accessible records of data and analysis. Software is fitted with automated features to facilitate the easy creation of documents, patient chart flows, and illustrations. Manual creation of tables and charts can be complex and time wasting when an organization uses computers without the support software.
Evaluation on how the Tool Contributes to Easy Workflows
Electronic health records are used during the treatment set up in the data entry of patients, which is further transmitted to either department for more checkups. An efficient workflow and safe healthcare practices are achieved through departmental coordination. For instance, after interacting with the patient, a patient is sent to the laboratory for testing. After this, the doctor gets the results online and does a medical prescription.
Evaluation on how the Tool Contributes to Interprofessional Services
Interprofessional care is realized when the electronic health care approach has been efficiently used. The patient’s satisfaction is realized when they are satisfied with the treatments given. The policy that restricts the flow and use of data ensure privacy about the patients’ health status. In some cases, patients may question the treatments and think they are false. Circumstances such as wrong medications may occur due to errors done in the laboratory. Electronic records, therefore, minimize these mistakes and offer required and relevant treatment plans.
Policy Statement
Information stored within the electronic health record should be restricted between healthcare providers, vendors, and patients. The primary purpose of this policy statement is to establish the standards of the tool’s operation to ensure efficiency (Keshta & Odeh, 2021). A certified electronic record that has been tested and reviewed must be used in compliance and incentive programs. The main goal of an electronic health record program is to encourage health facilities to use software that uses technology that meets the program’s requirements. The usage of malicious software programs can lead to data access by other people, which is against the rules of operation.
Software providers must allow the testing of electronic software before purchase. The implementation process must ensure that the electronic systems used are relevant. Before the purchase, the testing of the workability and efficiency of the software must be done manually. Vendors must give and demonstrate further explanations to avoid issues associated with improper usage (Wanyan et al., 2021). The software dealers should be held responsible if the testing fails to meet the required objectives and be ready to offer an alternative.
The software vendors must be prohibited from interfering with the normal flow and use of data stored in the system. Some of the interventions might be made when they may block the healthcare organizations from using the systems. Further, to protect the privacy of the data stored, the vendors should not be allowed to access the systems after selling them. Therefore, the organization should set unique passwords to protect data from being hacked and d promote privacy (Carlin et al., 2021). The patient access to online data concerning their data should also be minimized.
Guidelines for the Use of Electronic Health Record
The following guidelines are followed to use an electronic health record in any health facility effectively. The first step is creating an implementation roadmap to evaluate all the tasks and processes executed by the health caregivers, patients, and staff. Managers develop an internal team of hosts that will be monitoring the records by the healthcare giver s (Klompas et al., 2021. Secondly, recruiting an electronic health record committee from the various departments to aid in the outline of the expected implementation cost and the total budget is essential for planning.
The budget calculated involves the training cost, consultancy, and customization consultancy from the electronic health record vendor. The migration of patient data to the electronic health record tool is the third guideline. This can be done by conversion of paper records to electronic for compatibility. Data verification cleansing ensures that only the essential records about the patients are kept. Creating databases in the electronic record and allocating each section a particular set of data enhances easy organization. The mapping of legacy information follows a testing and verification procedure.
Creating a user-training program to ensure that the personnel involved know the tool’s usage. There should be clear communication channels for information flow between the departments involved. The role of each individual in the success of the flow of information should be emphasized (Melnick et al., 2021). Platforms to allow feedback by the patients on the experience gained during the usage are critical. This is essential since it enables the health organization to improve patient services.
References
Carlin, C., Peterson, K., & Solberg, L. (2020). The impact of patient‐centered medical home certification on the quality of care for patients with diabetes. Health Services Research, 56(3), 352-362. doi: 10.1111/1475-6773.13588
Keshta, I., & Odeh, A. (2021). Security and privacy of electronic health records: Concerns and challenges. Egyptian Informatics Journal, 22(2), 177-183. doi: 10.1016/j.eij.2020.07.003
Klompas, M., Rhee, C., & Baker, M. (2021). The universal use of N95 respirators in healthcare settings when community coronavirus disease 2019 rates are high. Clinical Infectious Diseases, 74(3), 529-531. doi: 10.1093/cid/ciab539
Melnick, E., Sinsky, C., & Krumholz, H. (2021). Implementing measurement science for electronic health record use. JAMA. doi: 10.1001/jama.2021.5487
Wanyan, T., Honarvar, H., Azad, A., Ding, Y., & Glicksberg, B. (2021). Deep learning with heterogeneous graph embeddings for mortality prediction from electronic health records. Data Intelligence, 3(3), 329-339. doi: 10.1162/dint_a_00097
Appendix
Guidelines on the use of an Electronic Health Record:
- Creating an implementation roadmap to evaluate all the tasks and processes executed by the health caregivers, patients, and staff.
- Recruiting an electronic health record committee from the various departments.
- The migration of patient data to the electronic health record tool.
- Data verification cleansing ensures that only the essential records about the patients are kept.
- Creating databases in the electronic record and allocating a particular set of data for each section.
- The mapping of legacy information follows a testing and verification procedure.
- Creating a user-training program to ensure that the personnel involved know the tool’s usage.