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founding to the electronic wellness check disposition (EMR) entree to the electronic checkup Record (EMR) Gary L Williams Western Governors University Introduction to the Electronic checkup Record (EMR) The in the buff millennium has produced m any(prenominal) flip-flops in the human beings as we know it. Our national gage which seemed to be imperme satisfactory has revealed its vulnerability to being br separatelyed. Re ingredient September 11, 2001 when the hi-jacking of intentiones lead to the destruction of the Twin Towers in New York City, and severe damage the Pentagon in Washington DC.Now our wellnessc be organization has now moved into the information spicyway. How you whitethorn intercommunicate, done the introduction of the EMR. So provide the EMR be safe and secure? Let us investigate. So right what is the EMR? There atomic number 18 many formal definitions but the unit of measurementy that stands come out of the closet and pass oning be used today i s from the wellnessc atomic number 18 teaching and Management Systems Society (HIMSS). It states The Electronic Health Record (EHR) is a longitudinal electronic depict of uncomplaining health information generated by adept or more encounters in any business organization delivery setting.Included in this information be enduring demographics, progress notes, problems, medicines, vital signs, past aesculapian history, immunizations, laboratory information and radio put downy reports. The EHR automates and streamlines the clinicians work ex exd. The EHR has the ability to generate a thoroughgoing(a) record of a clinical patient encounter as head as supporting opposite c atomic number 18-related activities directly or indirectly via port wine including evidence-based decision support, quality management, and outcomes reporting. (HIMSS) Within this definition there is a flock of formation components.Think of it like the octuple Introduction to the Electronic Medical Rec ord (EMR) dividers that were found in the authorship medical record. For showcase, you may see headers like, medication record, order portal, care for assessments, the plan of care, education, radiology, cardiology, etc. Under the medication substantiation lays the eMAR, medication history, and reconciliation. Each band with the click of the mouse forget clean a new file within this record. The design is formatted to follow a systematic flow with check boxes, drop down tilts, or exhaust text space to document the patient bob upings, activities, and assessments.The EMR impart crap many benefits for the entire healthcare aggroup and the patient. By development and design with the service of key personnel, the EMR should flow and make financial support easier. By having a ex repositionable flow and options to document the standards of care, documenting should become easier and endure more consis 10cy. Take for example a urine description. You may see for color descrip tion amber, yellow, red, clear, or tea. Then cloudy, turbid, clots, or mucous followed by malodorous, sweet, or pungent. This pull up stakes provide a means of potential measurement for Evidence-Based Medicine (EBM).How many patients with UTI receiving Bactrim DS wear amber mucous pungent urine on a GU unit? Can you see the pattern? The EMR will promote in critical thinking as well. Your physical assessment for instance may be by body system or a complete head to toe assessment. These screens will swear out the foster in reminders of required documentation. The cheer may receive a task list for a certain procedure or required documentation of a high risk factor, such as f on the whole(prenominal) precautions, to alert the bed position encourage or technician that the document is due or past due.Introduction to the Electronic Medical Record (EMR) The EMR will provide real magazine data and reports from confused disciplines within the healthcare facility. For instance, a Vanc omycin trough was ordered at 0700 and its 0900 and the IV medication is due. By selecting the laboratory tab your result will be there in seem of you before the dose is administered. The analogous can be expected of radiology imagining results, EKG, stress test reports, a bedside capillary glucose test done by the technician. No more inquisitory through multiple computer systems or piles of lab results to find the data you collect.The information is there and readily available. health care providers have the chirography of a deranged mad scientist. How often do you have multiple treats trying to determine what Dr. Hyde just wrote? What if you guess wrong? Now you status that call to Dr. Hyde for clarification when you have a multitude of things to be doing. With Computerized supplier Order Entry (CPOE), no longer will guessing what was pen be an issue. Standard order sets will be available with the fortune to be individualized or modified from a pre-determined list of ommo n orders for custom admission or for specific disease treates like the Acute myocardial Infarction. Included may be diet, activity, vital signs, IV fluids, labs, EKG, PCXR, or consults. As touched upon earlier with the urine sample report, there is a unnumberable of potential data that can be extrapolated to form reports for research and to encourage with the EBM. What is the average number of days for patients on the ventilator for June, 2011? How many patients in the rehabilitation unit have hug ulcers? Maybe a nurse says to the unit manager that it seems like a large number of the patients on the unit have C- Difficile?A report can be sink to show Introduction to the Electronic Medical Record (EMR) trends of the patients with this condition. Maybe its a hand washing issue or cross contaminant from multi-use bathroom facilities. There are many opportunities that would at crush have been difficult to track from the old paper medical record. Identity thievery is rampant in t his world of applied science. How will the EMR be secured? How can the nurse gravel the EMR? forthwith home computers are almost essential. The same virus and malware that affect your home computer can infect the EMR if security is lacking.The carrying engineering science team will provide the overall security for the system by continuous upgrades to computer software like antivirus and firewall protection. Each team member will be issued a unique log-in and war cry to coming the EMR. This must be kept strictly confidential for the nurses protection. This secure log-in is like a finger print of the assign user. When the EMR is accessed, there is a clipping stamp of what records were accessed, for what length of time, and by whom. A secure trail of entry into the EMR can be traced. What is the Personal Health Record (PHR) and how does it differ from the EMR?The PHR is essentially the same document that you would produce in the Physicians Office. The PHR can be completed online either through a Physicians Office or through an remote resource. Things that would be included in the PHR faculty be your anticipate, address, telephone number, look of birth, and possibly the social security number. This record could also contain your Physicians name and phone number, the list of your current medications and dosages, a list of current and Introduction to the Electronic Medical Record (EMR) past medical conditions, and passed functional history.This character reference of a record is usually well-kept by the patient themselves. The PHR will differ from the Electronic Medical Record in that the Electronic Medical Record is property of the Health Care facility and not the consumer. The in-person health record becomes more vulnerable to breaches in security since it is observeed by the consumer. For example, I might give my sign on and password to my family or friend to input data for me. This obviously breaches ones security. This allows access to thes e individuals to falsify ones personal health record at will.The website that chief(prenominal)tains the personal health record may not be as secure as that of the Health Care facility. The Electronic Medical record is usually maintained by the healthcare facility, outpatient clinic, or Physicians Office. These healthcare facilities must maintain high security to protect the information within that medical record. In 1996, Congress passed a law entitled The Health Insurance Portability & duty Act (HIPAA). This law was designed -To improve portability and continuity of health indemnification coverage in the group and individual markets. To combat waste, fraud, and abuse in health insurance and health care delivery. -To reduce costs and the administrative burdens of health care by improving efficiency and force of the health care system by standardizing the interchange of Introduction to the Electronic Medical Record (EMR) electronic data for specified administrative and financia l transactions. -To consider protecting the privacy of Americans personal health records by protecting the security and confidentiality of health care information. (James) The security and confidentiality are par quantity. Fines are levied as a result of a breech to the HPPA law.There must be alerts to vulnerabilities, safeguards to help protect the EMR and the Information Technology team must be able to advert affirmable threats. Using an EMR (electronic medical record) has no absolute right and wrongs in either computer equipment or software for HIPAA compliance. Usually there are four areas to examine -Physical Security can your computers with patient data be stolen? -User Security can anybody log on to the patient database? -System Security what happens on a hard drive crash? -Network Security can self-appointed persons outside your facility access patient data? Milne, 2006) Security is neer easy to maintain it requires continuous safeguarding. As a team we are all resp onsible to sanction in the security of the EMR. Always log on and off when you are no longer Introduction to the Electronic Medical Record (EMR) using the bedside computer. Always check before charting that it is so you that is longed into the system and that only one patient record at a time is undefended for use. The EMR can be a valuable machine for Quality Improvement (QI). Through the design phase, a number of mensurable data can be make into the EMR for report generation.If the team cherished to look at the number of times vital signs were not put down as dictated per Policy & Procedure. This data can be built into the system and reports run daily, weekly, or monthly. The same thing can be built to monitor for overdue or omitted medications. This can be only expanded to identify which team member is involved and to check for trends. info may also be collected to support EBM. For example, tracking the effectiveness of two different antibiotic treatment regimens of a se lected disease process may be used to support a change in the disease treatment (e. . antibiotic A showed improvement in five days where as antibiotic B showed improvement in ten days. ) Here again the possibilities seem long. Think of the time savings for all the key people that would be required to look through endless paper medical records for this type of data collection in the paper medical record. So how does the EMR come to fruition? It snaps a large team of various specialties and specialists to develop the EMR. It starts with the Healthcare system researching and then purchasing the best system to fit the companys needs and requirements.Once purchased, the owner of the software will deploy a team of specialists that will assist the Healthcare systems team to design and develop the contents and flow of the EMR. The team includes sr. management which will assist in the purchase and be the politics authority of the proposed Introduction to the Electronic Medical Record (E MR) work flow before implementation. There are many subdivided teams. Nursing will have Subject Material Experts (SME) that will be the voice to assist in the flow, wordage, and design of the nursing components of the EMR. The SMEs will be from every de collapsement of nursing.From this group will be the Super User. The Super User will act as the cheerleader for the project development and will be the main source for assisting with the Go Live of the EMR. The Information Technology (IT) will be a multi-tiered group ranging from System Support Analyst or the front line of communication, the Computer Programmers and System Analyst or the builders and troubleshooters, to the Project Managers or the supervisors of the IT team. Nursing will also have the Clinical Informatics employment Analyst who will be the voice between nursing and the proficient side of issues, concerns, and development.The End User which is the front lines of nursing and everyone that will be using the system for documentation. And last but not least will be the Educators that will teach the system to the entire team. This is a quite a large of individuals working as the voice of the EMR development and implementation. In conclusion, change will be rough at times but change is necessary for progression. Be positive and listen to the teams and the tips that are offered. Assist each other as support with the continued learning and development of the EMR. The Technology age is here and we should all reap the benefits of this endeavor.Remember how Florence Nightingale was the frontier to nursing as we know it. Well each of you deserves a pat on the pricker as you are the pioneers that have lead nursing into the technology phase of the Electronic Medical Record. You as well as are a part of nursing history. References HIMSS. (n. d. ) EHR Electronic Health Record. Retrieved from http//www. himss. org/asp/topics_ehr. asp James, R. (n. d. ) What is HIPPA? Retrieved from http//www. dhmh. state. m d. us/hipaa/whatishipaa. hypertext mark-up language Milne, M. (2006, March 6). HIPAA in a Nutshell Guidelines for EMR and Paper Medical Records Compliance.Retrieved from http//ezinearticles. com/? HIPAA-in-a-NutshellGuidelines-for-EMR-and-Paper- Medical-Records-Compliance&id=156737 Ten open ended questions. 1. When the EMR is first implemented on your unit, how can you assure the patient that you are competent in your profession? You will explain that you are a seasoned nurse and an expert in the nursing field. Today our facility is introducing the new EMR which will benefit you in the future. This will wad a little more time for me to learn and I do not want you to feel like you are being ignored. I may have to ask you a lot of questions as I go through each section.Please feel free to ask me any questions or concerns that you may have. Our goal is your comfort and safety though the high quality of care. 2. On the day of Go-Live, how can your unit best assist you in providing su pport as you learn this new technology? My unit manager should over staff initially as we learn the new system. I can foresee the nurse being so inhumed in the computer that the delivery of care might be too slow initially. Having the extra staff will decrease the patient rouse and allow extra hands to assist with the delivery of care. 3. As you learn the new system there will be some pass judgment frustration.How can you divert this frustration so that your patient doesnt instinct that something is wrong? We will need to have the Super-User and Analyst available to assist us as problems or concerns occur. It is imperative that the bed side nurse remain positive an up beat as we learn. I mention maybe huddles through out the day away from the bed side to discuss our concerns. We dont want the patient to feel uncomfortable. 4. Your patient asks you why it is important to have the computer charting. Briefly tell me what you might say and why? The EMR is being implemented througho ut the area as well as world wide.As you record develops, we will only need to verify some of your past medical history, allergies, medications, etc. These types of data will flow from one visit to another making you care easier as the data is readily available. No more waiting for old charts to get along and thumbing through page later on page of data to look for relevant information. 5. How do you perceive future benefits of an interoperable EMR? It will be possible in the future as the EMR progresses, that your hospital record, physician office record, out patient records, and pharmacy to communicate with each other.By doing so, some potential errors may be thwarted. For instance, maybe you are not able to recall all of your home medications and your consulting physician decides you need a new blood pressure medication. If the records could speak to each other then this physician would be able to see that you were already prescribed an antihypertensive medication or the pharm acy might catch the possible error. 6. Futuristically, lets say you take a dream vacation to a foreign country. While on your visit you become ill and collapse unconsciously.How can the interoperable EMR potentially be a benefit in this case? If the system develops into a world wide communication link, then with limited data possibly the hospital in the foreign country would be able to access and utilize my EMR to provide answers in how to deliver the best possible care for me. So if I went in with a suspected ruptured appendix, by accessing my EMR surgical history it would be noted that I have had an appendectomy ten years prior so the focus could be directed at another possible cause. 7.Your patient states to you that she hates the computer and that it is the devils advocate. She is tearful and appears anxious. How might you hairgrip this as you are in the middle of documenting in the EMR? You should stop what you are doing and maybe sit beside the patient and gently hold her ha nd and ask what seems to be troubling her? She might say she feels the nurses spend more time touching the computer and no time touching her, as you just did, and that we come across as cold and not caring. We need to embody that patient interaction is still paramount to the overall delivery of care.Take time to interact with the patient. Then step foul and document perhaps explaining what you are documenting and why it is important to her care. 8. What do you anticipate will be your plan of action when the computer system is down? What will be your back up plan? If the computer is down for a set amount of time, as determined by the hospitals administration, then the paper chart will be utilized. If the downtime is for an extended period of time, then this data would be scanned into the EMR as soon as possible after the computer system is back on line.If the duration was short, say an hour or so, then this data should be manually documented back into the EMR with the assessment ti me documented. 9. How do you anticipate computer physician order entry being a benefit? For one legibility No more trying to decipher what you think may have been written. It will be clear and concise. excessively the physician may be able to look at documentation form somewhere other than the patients unit and decide orders need to be given. He can simply do computer order entry and a task will appear for new orders.If the order is anything other than routine, a call should be placed to alert the nurse of the priority. 10. What do see as a benefit to Quality Improvement by the institution of the EMR on a unit basis? We will be able to track data at a faster and higher(prenominal) accuracy a opposed to thumbing through paper record after record searching for data collection. The data collected can be as concise as to a particular nurse or a specific health issue. The data collected helps to support EBM change.