NR 361 Week 2: Experiences With Healthcare Information Systems

NR 361 Week 2: Experiences With Healthcare Information Systems

NR 361 Week 2: Experiences With Healthcare Information Systems

Share your experiences with healthcare information systems, past or present. Has it been an easy transition or difficult? Why do you believe your experience has been positive or negative? If you are currently not working in a healthcare setting, how has the medical record exposure in nursing school impacted your current knowledge?

I have worked in a variety of healthcare settings throughout my career before I became a nurse. You could even consider lifeguarding part of healthcare because I was CPR certified, although I didn’t ever have to document anything or save anyone. I worked in a doctor’s office for a few years while I was starting school. This office was private practice, so they didn’t have an electronic documenting system. All the charts were paper, and they were very heavy! If I took a call from a patient, I had to find their chart in the files and hand write what they needed and give it to the doctor for him to reply. I learned spelling and medical terms very quickly! Although this system mostly worked for their needs, I sometimes found other patients results in others charts. Every result was faxed to us and sorted and filed by hand. Therefore, a lot of mistakes were made and there wasn’t a great way to monitor that the correct papers were getting into the correct charts. If a specific result was lost, there was really no way to find out where it went, we would just have to have another copy faxed. Thankfully while I was there nothing catastrophic happened, but with no safeguards in place, it’s really only a matter of time. In a study comparing electronic documentation verses conventional (paper) charting, this found that the electronic documenting showed more diagnoses for each patient, less false or redundant ICD codes, and less time spent on documenting (Stengel, Bauwens, Martin, Kopfer, & Ekkernkamp, 2004). Improper or false ICD billing codes can get you in a lot of trouble, even if you’re not doing in on purpose. Medicare fraud is highly monitored and can negatively affect a physician’s medical license. Not to mention the potential repercussions for the patient receiving wrong information and potentially having to pay more money unnecessarily.

I found the transition from that old paper system to an electronic system to be very smooth. I often felt like I lacked detail in some instances and I know how important documenting is. But the amount of time I spent hand writing requests in the chart took away from the amount of detail I could put into it. I was already spending extra time after the office closed to call back the patients who had called that day, I didn’t have any extra time to write more. I can type a lot faster than I can write, so an electronic system would have really helped streamline this office. I understand how expensive it can be to convert, so I realize why they never changed over. I used Epic documenting now and I could not imagine what it would be like to try and document a hospital patient with a pencil and paper. I already spend a lot of time charting, I feel like I would never get the amount of detail necessary while trying to hand write all my documentation.

Stengel, D., Bauwens, K., Martin, W., Kopfer, T., & Ekkernkamp, A. (2004). Comparison of Handheld Computer-Assisted and Conventional Paper Chart Documentation of Medical Records: A Randomized, Controlled Trial. Journal of Bone and Joint Surgery, 86(3), 553-560.

Share your experiences with healthcare information systems, past or present. Has it been an easy transition or difficult? Why do you believe your experience has been positive or negative? If you are currently not working, how has the medical record exposure in nursing school impacted your current knowledge?

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My experience with healthcare information systems has been generally good. When I started in oncology I would have utterly failed if it was not for healthcare information systems. When I am doing telephone triage, I have everything on the internet at my fingertips. Having access to all of this allows me to answer patient questions in real time. If I am uncertain if a certain adverse event patient is experiencing is expected with the particular medication he or she is on, I can simply look up the package insert for the drug and quickly find out. According to Hebda, “an information system, at its simplest, is a combination of computer hardware and software that can process data into information to solve a problem” (2019, p.135).  I use these sorts of systems daily in my nursing career. My current EMR comes with free access to UpToDate. If I need to know anything about a drug, I can simply click the link and it will take me to page regarding that drug. I utilize NCCN template guidelines when building new regimens into our EMR, I can easily trend and graph a patients’ tumor marker with a click of a button providing the patient with a visual, easy to read snapshot of how their treatment is working for them. It seems the benefits are endless yet there is some apprehension when it comes to implementing new systems.

All transitions are difficult. Implementing a new EMR is especially difficult. I have gone through a full EMR change and am now working on yet another. There is no perfect system and the learning curve is always step. Ljubicic et. al. explains some of the challenges facing these types of transitions are including but not limited to limited staff, budget concerns, and the fact that the work force is aging and my not be as tech savvy as a younger workforce. This all the in setting that patients expect us to be cutting edge and provide the most up to date, quality care possible (Ljubicic et. al., 2020).  Each new system is advertised as the “best out there” yet there is no perfect system for anyone. Add on that these systems must constantly update to stay cutting edge means that you sometimes have to relearn how to use them. I can see how there is apprehension. The nature of my position puts me central in the development/transition to a new system. Working with these companies that have developed a program a certain way that they assume works for everyone is difficult at times. They are often not clinicians and do not understand why their prescribed workflow does not work for our particular office/specialty. It is a battle and a stress particularly when it seems we are speaking different languages. It’s a high stakes game. Our clinic works as a well-oiled machine to keep up with the demands of patients; if a new EMR does not help us increase efficiency then it is useless to us. I must ensure that proper workflows are in place before we go live. We know that these healthcare information systems can help us improve care but I can also see how it can have negative outcomes as well.

Also Check Out: NR 361 Week 3: Standardized Terminology and Language in Informatics