HCS/533 Read Me First

Read Me FirstHCS/533

Week Two

Introduction

The topic of discussion this week is data that support patient care in both the hospital and physician’s office. This data is also used for medical research, which relies on patient data, and yet it is critical to protect patient confidentiality when using this data for research.

Computerized patient records have been implemented in some form in almost all health care environments. We will discuss the various degrees of computerization, focusing on the components and uses of electronic medical records (EMR) and electronic health records, which bring together a wide range of medical and health information pertaining to an individual patient.

Health care professionals collect patient data to providethe best care possible to patients. This data might also be used for research andto maintain public health. Because of this, health care organizations may be required to provide patient data to public agencies. Patient permission is typically required to share data for research purposes. When data are used for research, steps must be taken to protect the patient’s identity. Yet at times, the patient’s identity is required. The challenge for health care providers is to find the proper balance between patient privacy and quality research.

This week in relationship to the course and the program

Quality data are at the core of quality patient care, timely financial reimbursement, and sound medical research; these three concepts are dependent upon consistent data collection, recording, and sharing protocols. Understanding the flow of data, whether in a physician’s office or a hospital setting, lays a foundation for understanding automated health care information systems.

Hints for a reading strategy of the assigned materials

As you begin your assigned readings, you should look for two overriding themes. The first is data, an essential component of healthcare, especially in health care information systems. Pay attention tohow health care professionals obtaindata.How do they ensure quality data collection? Whatare the uses for the data, and how do these uses differ? Finally, how is this data stored and maintained? This question leads to the next overriding theme in this week’s reading: data recording or storage.

Data storage has changed drastically in the past 30 years, moving from an archaic folder–and-paper system to the EMR system. As you read about EMR, remember to focus on the advantages EMR offersas opposed to the old method of data storage. How do the major functions of both systems compare? Does EMR have limitations? How would you differentiate the five levels of computerization within the EMR structure?

Some questions to ask as you hone your critical thinking

As you read the material, ask yourself the following questions:

  • What is done by your organization to ensure the quality of health care data? Are protocols clear, understood by all, and taken seriously?
  • Develop two or three ideas to ensure the accuracy of data in your organization.
  • Analyze how close your organization is to implementing EMR. What would be the benefit of fully implementing this system? Is it worth the cost?
  • Many doctors are resistant to computerized physician-order-entry systems, preferring to write out the order for a nurse or assistant to handle. We know, however, that these systems reduce errors. Why are physicians resistant? What can be done to counter this resistance?

Summary

Without quality data, quality health care would not exist. Imagine what could happen ifa physiciandid not address a patient’s allergy, prescribed an incorrect dosage of medication, or recorded an incorrect diagnosis code. Medical professionals who understand the relationship between data andeffectiveness of treatment—and their role in ensuring this effectiveness—are better able to deliver quality healthcare.

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