LIS5418 Introduction To Health Informatics

Question Describe the key components of a standard electronic health record system. Discuss the benefits and challenges of computerized order entry (CPOE) and clinical decision support systems (CDSS)? Answer The Key Components Of A Standard Electronic Health Record System The fundamental components of an Electronic Health Record System (EHRS) include: Patient Management Component This is an essential constituent of an EHRS which is used for patient cataloging, admission, transfer, and discharge often abbreviated as ADT. The cataloging process involves capturing patient’s details such as insurance information, demographic, contact information and so forth. After a client’s registration in the in the EHR, for the first time, a unique ID (frequently known as “Medical Record Number”) is created. But when a patient had visited the healthcare center before, a unique “encounter” number is generated (Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety.; Institute of Medicine (U.S.). Board on Health Care Services., 2013). Billing System The billing system (infirmary as well as specialized billing) is applied in capturing all charges produced while taking care of a patient. These costs create claims or dues, which are later surrendered to the insurance companies, followed and finalized. Overlapped on top of the principal presentation coatings is usually a data stratum, which is fed information by the EHR. This data layer permits healthcare specialists to screen Key Performance Indicators, view control panels with relevant corporate statistics, and run diagnostic reports to observe and develop the general performance of the association (James M Walker, Bieber, & Richards, 2005). One of the achievements of applying the records taken through EHR’s is the capability to track administrative expenditures, portfolio, as well as income cycle performance. These fundamental farm duties were incredibly complex in the pre-EHR age. Clinical Component: This constituent is able to accommodate manifold sub-components like Computerized Provide Order Entry (CPOE), automated certification, nursing element and so on. CPOE consents benefactors to enter instructions which are required for client management unswervingly on the computer. This constituent can use medical decision sustenance implements, for example, drug-allergy, drug-drug, and drug-diagnoses interfaces. This component also permits providers to enter numerous commands from order arrays (Feldman & Alexander, 2012). Automatic certification by providers enables them to document records for instance History & Physical, referrals, exoneration sum-ups, operational proceedings, etc. Compound tools might be applied to allow electronic documentation such as prototypes, transcription services, and speech recognition. The dispensing chemist’s system permits for preserving a medication formulary, filling medicaments as well as double-checking any guidelines placed providers in the EHR (Williams & Samarth, 2011). Treatment module sanctions for an assortment of important customer details, for example, essential ciphers, input and output among others. This constituent correspondingly permits for Medication Administration Record (MAR), barcode suppository nursing and documentation. Radiology Information System Picture Archiving & Communications System (PACS) and Radiology information system (RIS) are both commonly employed while managing client ordering process, workflow, outcomes as well as the images themselves. Laboratory Component Laboratory modules are characteristically separated into two sub-components, namely, Capturing results from laboratory apparatuses, and amalgamation with instructions, billing and lab equipment. The lab constituent might either be assimilated with the EHR or exist as a separate brand (Bali, 2013). The Benefits And Challenges Of Computerized Order Entry (CPOE) And Clinical Decision Support Systems (CDSS) The CPOE and CDSS are both associated with safety practices. Successful implementation of these schemes aid a health care association in enhancing safety while using Electronic Health Record System. The application and usage of CPOE with CDS is quite multifaceted and brittle, necessitating careful preparation, execution, and preservation in order to function appropriately. In an EHR-enabled health center setting, providers depend on expertise to sustain and manage the intricate procedures connected to CPOE with decision support, and this dependence generates possible safety jeopardies which can be mitigated through the implementation of the suggested practices (Kuperman, et. al., 2007). The application of CPOE with CDSS is able to advance treatment safety and guarantee which benefactors who automatically command analytical assessments and discussions linger in the communication circlet. Nevertheless, certain practices associated with CPOE can generate security perils (WolfstadtJerry et. al., 2008). For instance, incomplete acceptance of CPOE, or an absence of CPOE nursing (for example partial data entry or unnecessary application of free text), can bring about dangerous situations. CDS, regardless of whether separate or incorporated inside an EHR, is premeditated to support the medical policymaking procedure at the theme of care. The present latitude of CDS concentrates mainly on suppositories, lab analysis, radiology processes, and scientific reference literature (Kabene, 2010). Considerable indication recommends that well-planned decision support system not only improves the superiority of care but also unswervingly progresses customer security through lessening conjoint mistakes and averting oversights or unexploited opportunities that lead to patient impairment. However, sustenance features and poorly instigated IT systems have been revealed to present faults which unfavorably affect care. Various works of literature support CPOE’s importance especially in reducing the occurrence of an assortment of treatment errors, including severe blunders with the prospective for maltreatment. A Smaller amount of information is available concerning the influence of CPOE on ADEs, with no study presenting a noteworthy reduction in definite patient detriment. Correspondingly, sequestered CDSSs seem to prevent a variety of prescription inaccuracies, but with insufficient statistics unfolding decreases in ADEs or developments in other medical results. In conclusion, the studied CDSSs discourse concentrated on medication usage (for instance, antibiotic medicating) instead of more broad-spectrum features of treatment usage. Bibliography Bali, R. K. (2013). Pervasive health knowledge management. New York: Springer. Feldman, H. R., & Alexander, G. R. (2012). Nursing leadership: a concise encyclopedia. New York: Springer. Gilad J. Kuperman, MD, Ph.D. Anne Bobb, RPh Thomas H. Payne, MD Anthony J. Avery, MB, CHB, DM Tejal K. Gandhi, MD, MPH Gerard Burns, MD, MBA David C. Classen, MD, MS David W. Bates, MD, MSc. (2007). Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review. JAMIA (Journal of the American Medical Informatics Association, Volume 14 (Issue 1), 14 (1): 29-40. Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety.; Institute of Medicine (U.S.). Board on Health Care Services. (2013). Key capabilities of an electronic health record system: letter report. Washington, D.C: The National Academies Press. James M Walker, M., Bieber, E. J., & Richards, F. (2005). Implementing an electronic health record system. London: Springer. Jesse I. WolfstadtJerry H. GurwitzTerry S. FieldMonica LeeSunila KalkarWei WuPaula A. RochonEmail author. (2008). The Effect of Computerized Physician Order Entry with Clinical Decision Support on the Rates of Adverse Drug Events: A Systematic Review. Journal of General Internal Medicine, 23(Springer International Publishing AG), 451–458. Kabene, S. M. (2010). Healthcare and the effect of technology: developments, challenges, and advancements. Hershey, PA: Medical Information Science Reference. Williams, T., & Samarth, A. (2011). Electronic health records for dummies. Hoboken, N.J: Wiley Pub.

LIS5418 Introduction To Health Informatics

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