paperless hospitals. authors melanie hood mike kramer alyssa grayson sarah smith
TRANSCRIPT
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Paperless Hospitals
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Authors
Melanie HoodMike Kramer
Alyssa GraysonSarah Smith
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Objectives
• Define and describe trend• List and describe trend hardware and software• Identify, describe and review trend information and system• Describe advantages/disadvantages of using trend• Examine legal and ethical issues related to the use of trend• Describe technology - related competencies needed by the
professional nurse working with trend• Describe functions of the informatic nurse working with trend
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What is a paperless hospital?
• A computer-based record containing health care information. • This system will increase patient care and safety. • It is the potential of electronic medical records to provide large-scale
improvements in the efficiency, safety, and cost-effectiveness of health care
• They will eliminate or substantially reduce medication related errors in the facility
• This system will eliminate problems with legibility, ambiguous abriviations, and delays in order communication.
• It will clinically benefit by automatically verifying orders by checking dose, drug to drug interations, and allergies.
(Russ, 2010)
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HARDWARE
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Available Hardware
• Wireless tablet PC's• Scanners• Printers• Stylus • Touch Screens• Keyboards
Farcus, 2009. page 17.
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Wireless PC
A wireless PC is a computer that has the ability to become wireless and carried from patient room to room.
(Ellison, & Evans, 2003)
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Wireless PCs will have WiFi capability.
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The PCs that the hospitals would be equipped with would have software with the ability to turn these hospitals
paperless.
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Available Software
• Billing• Electronic prescriptions• Physician's orders• Nurse’s notes• Laboratory results • H&P• Advanced directives• Nutrition • Non- physician orders• Etc.
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Electronic Prescriptions
Increase patient safety and reduce pharmacy callbacks.
• Quick prescription refill processing• Increases prescription accuracy• Color-coded patient drug history maintains current,
expired, ineffective, discontinued, and sample prescriptions.
(Allscripts electronic prescribing, 2009)
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Clinical Information System: Accustat EMR: • Order entry system• Manages transcription cycle & reduces errors & costs• 24/7 Access to transcription
• Dictate, prioritize, and tracks jobs in real time
• Automatic attachment to patient EMR
(www.acustatemr.net)
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Who Uses and benefits from AccustatEMR? Primarily used by Physicians Benefits:• Nurses• Patients • Medical secretaries
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AccustatEMR enables the physician to:
• Provide online billing• Document test results and lab findings• Document physician's progress notes and orders• Prescribe new medications for patients
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More About Accustat EMR...
• Configuration: Point of Service system
• Regularly exceeds the American Healthcare Association Integrity Standards (AHIMA)
• Routine audits by HIPAA compliance team
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Reasons we recommend Accustat EMR:
• Personalized to individual facility needs
• Physician and patient convenience
• Cost effectiveness• Reduction in serious medical
& prescription errors• Easy access to edit, search,
and view medical transcriptions
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• Personalized care• More accurate patient
billing• Less med errors
• Legible physician orders• Emailing of charts• No way of wrong patient
charting
(Lamburg, 2008)
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Disadvantages
• Cost• Educating Staff• Complete Cooperation• Time Management
(Lamburg, 2008)
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Ethical/Legal Issues
• Paper-era state regulations that may not permit EHRs o state regulation of medical records is based upon the rules of paper records
(Shay, 2005)
• HIPAA’s privacy and security regulationso unrelated physicians of record sharing organizations can locate, request
and obtain the medical records of patients
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Ethical/Legal Issues
• Anti-trust Lawso The laws prohibit anti-competitive behavior, including price fixingo Sharing payment information could enable competing providers to collude on
prices and violate the anti-trust laws. (Shay, 2005)
• Creating a Legal Document o EMRs must be stored legally, if not they may be deemed invaildo if they do not meet legal requirements, the payor can sometimes deny
the claim
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Competencies required to work in Paperless Hospitals:
• Ability to:o Access and use emailso Search databases and obtain informationo Navigate institution specific software regarding
charting and administering medso Operate Windows applications
(McGonigle, 2009)
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Functions and Responsibilities of the INS:
• Possess the knowledge and skills specific to paperless hospital software, hardware, and the clinical information system used by their facility
• Use critical thinking and computer skills to assist with hospital technology
• Teach and assist others with learning new information and technology
• Assist with implementation and evaluation of the Clinical Information System
(McGonigle, 2009)
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In conclusion:
1.A paperless hospital will require new hardware/software
2.There are many different software to choose from3.A customized software is needed for each area of
healthcare4.This system will require all staff to transition to a
different way of thinking5.The advantages out weigh the disadvantages6.A paperless hospital will change the way of
nursing
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References
Cucina, Russ. "Information Technology in Patient Care" (Chapter). McPhee SJ, Papadakis MA, Tierney LM, Jr.: CURRENT Medical Diagnosis & Treatment 2010: http://www.accessmedicine.com/content.aspx?aID=779189.
Allscripts ( 2009, July). Electronic prescribing - TouchChart eRx. Retrieved [date] from MDS Medical website: http://www.mdsmedicalsoftware.com/allscripts/electronic-prescriptions.php
Ellison, C., & Evans, D. (2003, October 14). Wireless networks. Retrieved from http://www.pcmag.com/article2/0,2817,1275533,00.asp Farcus, N. (2009). Introduction to computer hardware lecture. Nurs 457.
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References:(2009). Accustat EMR. In Digital Medical ASP Transcription. Retrieved December 1, 2009, from http://accustatemr.net/default.aspx.McGonigle, D. & Mastrian, K. ( 2009). Nursing informatics and the foundation of knowledge. Boston: Jones & Bartlett Publishers. Lamburg, S.I. (2008, May 24). Paperless or less paper. Retrieved from http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B75K6-4SK9CWR-J&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1121678625&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=795bc94818ea40d062fff6926535a25cShay, Edward F., and Esq..(2005). "Legal barriers to electronic health records." Physicans News. N.p., n.d. Web. 4 Dec. 2009. <http://www.physiciansnews/law/505.html>. "Legal Issues of the ELectronic Medical Record." Medical Practice Management Trends. N.p., n.d. Web. 4 Dec. 2009. <http://www.medicalpracticetrends.com/2009/07/19/emr-legal-issues/>.