An elderly patient has been admitted to the medical/surgical unit from the local nursing care facility. The new lab results in her electronic health record (EHR) indicate that she has methicillin-resistant Staphylococcus aureus (MRSA) in her urine. She is placed on contact precautions per the hospital guidelines.
The health care provider arrives to examine her new patient and inquires about the need for contact precautions. The nurse explains the lab results reveal the patient has MRSA in her urine. The health care provider states that she reviewed the patient’s lab results in the emergency room and the urine results were normal. The unit coordinator reveals to the staff nurse and nurse manager that this is the third incident this month of lab results being uploaded to the wrong patient’s EHR when admitted from the emergency department.
Write a 1,050 to 1,400-word paper based on the case study in which you:
Analyze the adverse trend, including how it affects patient care.
Evaluate the data that needs to be collected, reviewed, and applied in the decision-making process to address the adverse trend.
Evaluate the information system methods that will be used to collect the data needed in the decision-making process, including the source(s) of the data.
Evaluate the information technology and tools needed in each step of the decision-making process.
Evaluate any regulatory, legal, ethical, political, sociocultural, and financial issues related to the data and information technologies that will be used in the decision-making process.
Analyze at least two strategies used to advocate and access social justice in health care design and delivery.
Adverse Trend and Data Management
Analyze the adverse trend, including how it affects patient care
Uploading lab results to the wrong patient’s electronic health record system may significantly impact the quality of patient care provided by the hospital. This may also put the patient’s health at risk. The patient receives wrongful medication allowing the bacteria to multiply. This affects patient safety. Such errors also adversely affect the clinical decision making. This is because decisions are made based on wrong information. For instance in the case study, the hospital put the elderly patient in an isolation unit which was not supposed to happen. Such wrongful decision making puts at risk the health of all health care providers as well as other individuals. This is because the individual suffering from the methicillin-resistant staphylococcus aureus (MRSA) was not put in the isolation unit, meaning it was possible to spread the disease through contact to other persons in the nursing care facility and at home.
Uploading wrong results in the EHR also affects the privacy and security of the patient. It can also lead to increased cost of healthcare delivery to the patient, payers and the nursing care facility due to duplicate testing. Errors in the EHR system can increase exponentially impacting patient care to majority of the patients. Giving wrong results to a patient may cause mental anguish and pain. The patient is also put in danger by administering wrong drugs, which may even trigger allergic conditions. In some cases, uploading wrong results can lead to drug overdose or the patient receiving drugs he/she is allergic to. Lastly, uploading wrong results may lead to civil suits filed by aggrieved patients which adversely affect the nursing care facility’s image.
Data that needs to be collected, reviewed and applied.
Particular patient data needs to be collected and thoroughly assessed in order to address the adverse trend. The data collected should help the medical personnel ascertain the person to whom it pertains in order to avoid errors. Certain data attributes, if properly collected and documented can help eliminate mix-up cases. To start with, it is important to record the full name of the patient on the results. The data of birth should be included using the same format for all nursing care facility records. The patient’s gender is also important in ensuring that records match with the actual patients. Other important data which can be collected include the patient’s address, social security number and the phone number as well (“AHIMA,” 2013). These can greatly help in decision-making to avoid cases of wrong patient identification.
The demographic information provided by the patient may not be sufficient in eliminating cases of uploading wrong data in the EHR. Additional data should be collected to minimize the adverse trends (“AHIMA,” 2013). The nursing care facility should collect biometric information on patients which can significantly help in matching medical records in EHR with the correct patients. Biometric information collected on patients may include fingerprint information, photographs, and palm vein scanning. Additional checks may also include matching algorithms. Probabilistic algorithm can particularly be useful in analyzing the data stored in the EHR system.
Information system methods to be used to collect the data.
There are different types of information system methods used to capture or collect data in a typical EHR system. The first method involves entering the data provided by the patient directly into the EHR system. There are a number of data entry policies which guide the procedure. Additionally, front desk staff and registrars who often handle data entry should undergo training in order to improve their data entry skills to avoid errors such as duplication and mismatch of patient records. This method can be used to collect data such as patient’s name, phone number, gender, date of birth, address, and social security number. Second, templates completed by patients can be included in the EHR system. Third, handwritten documents can be scanned and the information uploaded in the information system. Patient details such as name and date of birth can be handwritten on a special form which is then scanned and uploaded in the system (“AHIMA,” 2013). Other handwritten reports can also be scanned.
Interfacing the various information systems in place can also help retrieve or access data easily. This involves linking or integrating the various systems in hospitals such that data can be fed and accessed from any point. Various systems can be integrated such as the electrocardiographs, radiology systems, pressure monitors, laboratory systems and others. Biometric information can be collected by use of computers with special scanners. Finger scans can be used to collect patient details and the information fed into the EHR system (Makam et al., 2013).
Information technology and tools needed in each step
There are a number of information technology and tools that are critical in realizing all the steps. Tools to provide physical access are necessary in all nursing care facilities. The first set of tools includes scanning and printing tools. These set of tools make it easier to convert paper records into electronic versions for easier storage in the EHR (Makam et al., 2013). The next set of tools includes desktops, laptops, and workstations. These tools provide physical access. Workstations are particularly useful when the treatment rooms are limited, or when the providers are many and hence the need to share. Notebooks and tablets can also be useful tools in capturing and storing patient data with ease. Servers are also required in each of the steps. Servers are of two types: client-based and web-based servers. Networking is also a critical requirement in an information technology environment. Networking allows connectivity between the computers and to the internet (Makam et al., 2013).
An interface should be provided for all medical devices so as to enhance connectivity. Medical devices which are properly integrated with the HER system enables registrars and other hospital staff to save time and costs and reduce errors which often result during transcription. Voice recognition tools can also be time saving.
Issues related to the data and information technologies.
The regulatory environment provides guidelines with regard to the documentation process using information technologies. The regulatory guidelines surround the copy functionality of the information technologies, timeliness and their accuracy. Ethical issues relate to the privacy of patient information. The information technologies must safeguard patient information against unauthorized access and misuse (Jamoom, Patel, King, & Furukawa, 2012). The nursing care facility is not supposed to share patients’ records not unless the patient authorizes it. In relation to finance, the data and information technologies to be used should be cost effective. The data and information technologies should provide efficiency with respect to minimizing documentation and administrative costs. Efficiency should also be achieved in terms of operational costs. It should be easy for the staff to work with the data and information technology systems. In relation to the socio-cultural aspect, the data and information technologies should not go against the religious beliefs or cultural practices of individuals. In addition, they should uphold the moral and ethical values of individuals.
Strategies used to advocate and access social justice
The nurses’ Code of Ethics encourages nurses to take action in situations where individuals or communities have issues with accessing social justice. In a nursing care facility, the major aim is to improve the quality of lives of all individuals who seek help. This includes the disadvantaged in the community as well as the vulnerable groups. In order to access social justice for the disadvantaged and the vulnerable groups, the nursing care facility must take action and partner with the relevant bodies that can be of help (Linsley, Kane, & Owen, 2011). For instance, it is possible to partner with community support groups or other organizations to improve health care delivery to the vulnerable and disadvantaged.
Various medical personnel such as nurses are given the right to practice and thus they must also take action against any health issues arising. Nurses can also use the mass media, community mobilization strategies, and direct political lobbying in order to advocate and access social justice. These actions should be taken with the key interest being the improvement of the welfare of the disadvantaged and the vulnerable groups. Health professionals must help people in all levels of society and without discrimination (Linsley, Kane, & Owen, 2011).
AHIMA. (2013). Assessing and Improving EHR Data Quality (Updated). Journal of AHIMA, 84(2): 48-53.
Jamoom, E., Patel, V., King, J., & Furukawa, M. (2012). National perceptions of ehr adoption: Barriers, impacts, and federal policies. National conference on health statistics.
Linsley, P., Kane, R., & Owen, S. (2011). Public health and the nursing role: Contemporary principles and practice. Oxford: Oxford University Press.
Makam, A.N., Lanham, H.J., Batchelor, K., Samal, L., Moran, B., Howel-Stampley, T., Kirk.L., Cherukuri,M., Santini,N., Leykum.L.K., & Halm, A.H. (2013). Use and satisfaction with key functions of a common commercial electronic health record: A survey of primary care providers. BMC Medical Informatics and Decision Making 13(86): 1-7.
Informatics Needs Assessment – HCS482