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Medical Infomatics

Page history last edited by brittney.schafer@iwc.edu 11 years, 3 months ago

 

                                                                                       Overview

 

                                                                                                                            

 

Medical Informatics is the application of information technology to the healthcare profession with the aim of creating tools and procedures that can help doctors, nurses, and other healthcare personnel diagnose and treat patients more accurately and efficiently [1]. Computer technology taken over and altered the way human beings complete daily tasks and is continuing to evolve as more programs and applications are created. Medical Informatics programs are integrating the way the science of medicine, computer technology and information science are used to enhance the quality of patient care through improved communication, documentation and efficiency. The use of computer technology is continuing to show improvement in enhanced patient health care, treatment and medical outcomes across the world.

 


 

                                                                  Medical Informatics: What is it?

 

                                                                                                                                      

 

Medical informatics are computer based application software systems designed to collect, store, study, manage, retrieve and share medical information between specific databases to allow for optimal medical decision making. Each program has minor differences and is at the discretion of the facility initiating the new flow of charting. While each program may slightly differ, the ending outcome is still a shared goal, improved efficiency in health care with limited medical errors. Some systems in small communities such as a county hospital or small town doctor’s office may use the simplest of computer program to provide efficient patient record keeping and billing, whereas larger communities such as a research hospital in larger cities neighboring multiple doctor’s offices can use informatics systems to communicate between each other and share patient records as needed. This type of system communication can allow access to patient medical records as needed at the fingertips [1].

 


 

                                                                                       History

 

Medical informatics is a relatively new field of study and has a long way to continue to grow. Talk about using a computer to process data begun with Charles Babbage. TO use computers for medical purposes was considered advanced technology and was not explored as a reasonable option until the 1950’s. Computer use to process and store medical data took off in the 1960’s as diagnostic systems and programs were being created and advanced quickly [1].

 

It was quickly determined that the use of computer analysis and diagnostic systems created speed and accuracy in diagnosing and treating infections. Stanford University was an original user of these systems and continued to advance them. Creators began to invent different types of systems to assist in medical technology advancement. Specialties such as blood clotting abnormalities, infectious bacteria identification and treatment, as well as medical information to the general public were the stepping stones of information that have combined to give us the current state of medical informatics professionals work with today [1].

 

Individual health records didn’t begin until the 1980’s and have been improved over the years into the CPRS (computerized patient record system) systems health care professionals currently use. These systems started as simple applications for patient record storage and processing, and have evolved to error prevention and long term trends of a patient’s health [1].

As general computer technology advances, so does the concept of medical informatics. Today, medical informatics technology allows health care professionals to record, process and analyzes patient information. The significant advancements in medical technology have allowed features to these systems to alert users of error, significant individual patient events and abnormalities, and ensure the “5 rights” are followed for patient safety.

 


 

                                                                                  Paper charting

 

                                                                                                                     

 

Before networks of medical informatics, or even simple single office computer charting programs surfaced, paper chart record keeping was the standard way to keep medical information stored and later analyzed. Any given day at medical office, each patient seen (ever) would have their own file. Within that file, would contain all there was to know about that single patients medical history. With each visit to the office, more contents were placed within the file and kept to review. At the end of the each visit the file was placed in cabinet or on a shelf with all other patient files that were treated or seen in the specific facility. This system left room for error, excessive money loss and lost medical information between facilities. If a medical emergency arose and a patient needed to be seen at a hospital emergency room, their past medical history were nowhere to be found.

While paper charts were a great method of record keeping at the time, it appeared to have many flaws and downfalls. Some simple, yet significant and life threatening problems medical personnel have been faced with due to this system include:

  • Patient visits outside of specific facility. If a patient was seen at another facility (say, a hospital visit), the records had to be copied or faxed to another facility to be added to their records (the patients main physician). It made duplicates of records, a waste of paper, costly and could cause confusion among providers.
  • Audits and Inspections. State members who audit records had to devote an enormous amount of time reading and rereading patient records in search for errors or malpractice. The bigger the client list of a single facility, the more charts needed to be screened. In addition to numerous clients, if a patient was drastically ill, their chart would contain more information, more information to audit.
  • Non-standardized Writing. Handwriting charts can cause a misreading from one person to another. A solution to improve this problem was the initiation of printing spread sheets to simply fill in. While time was not lost, numbers and letter can vary by each individual leading to misinterpretation and eventually errors. Chart ordered prescriptions for a medications can say a specific order and be interpreted completely differently. With the misinterpretation of a medical order from a single individual can cause a ripple effect of dispensing the wrong medication, procedure or products and cause even more problems.
  • Chaos. Trying to manage a room full of documents can be difficult for anyone. Trying to manage records on a daily basis can be downright frustrating for patients, staff and physicians. One misplaced document can delay a single exam and cause a ripple effect and postpone the rest of the day’s events for that office.

 

These are a few problems that have occurred over the years of medical practices, there are many more. Many facilities have already or are in the process of switching from paper charting to computer charting. Some are even going one step further, the networking their facilities with others nearby [4].

 


 

                                                                                Computer Charting

 

                                                                                                         

 

Computer charting may seem complicated to those who know little or nothing other than paper charting can be a big change and a big headache. Though paper charting has been the main way to record medical information for years, it seems the shift to computer charting is inevitable. The purpose of implementing computer charting is to promote accuracy and efficiency within the medical fields of care.

Some ways of promoting accuracy and efficiency in patient files with the use of computer technologies include:

  • Standardize. Standardization of medical information to obtain insists that all information has been covered and completed. An admission of a patient to the hospital can be caused by many things. A standard admit page in computer charts can allow for a patient to be asked the questions to get a baseline of the problem and provide information to begin treating sooner.
  • Easy Access. With paper charting, there is one chart. Computer charting is completed using an application to store the information and be accessed anywhere within the facility by approved personnel. A nurse may be looking at the latest vital signs entered on a patient, while at the same time a physician may be looking at current orders on the same patient.
  • Privacy. HIPPA is a fairly new law the prohibits the sharing of medical information with anybody other than medical staff on a need-to-know basis. With paper charting, anyone within range can physically hold and read a chart if no one is standing guard of the files. Computer charting allows charts to be locked down and only accessed by those who have ID names and passwords, and have completed proper training to use the system.
  • Space. The space requirement for a single computer that holds all patient records is as simple and small as a computer desk holding the equipment. With paper charts, laws require offices to keep all records for a set amount of time. To keep every record, offices would need to dedicate large amounts of time and space to coordinate a system such as file cabinets or shelving units. Computers can be placed on small portable or stationary desks near an electrical outlet.

 


 

                                                                         Current System Concerns

 

Privacy. Medical records are personal, private and confidential. The protection of this information became a large concern for the placement of privacy laws. In 1996 the HIPAA (Health insurance Portability Accountability Act) was created to enforce prevention of personal medical information being shared without consent from the individual themselves. Only particular medical staff that remain on a need-to-know basis are the only personnel who are granted access to a person’s medical information without consent [2].

 

Not only medical information protected but with this law, patients and providers are able to have a relationship allowing trust and willingness to share important information. A diagnosis is like a puzzle, without all of the pieces (information) a clear diagnosis is harder to make. This law plays a critical role in how treatment is determined and given to patients across the nation. When a patient feels safe and aware that their personal medical information will not be shared, their health concerns become [2].

Like all laws, effectiveness is determined by the amount of enforcement. The U.S. Department of Human Resources oversees, regulates and punishes HIPAA violations. Violation of this privacy act results with legal action and, depending on findings, can be punishable nationwide including sentencing to a correctional facility.

 

Black-Outs. Loss of electricity is a common problem that can affect an entire community. Weather conditions that affect electricity can be a serious problem not only to patients, but to the providers who care for them. Without access to patient information the provider must rely solely on their memory of the patients’ information and any current paper charts lying around. Hospitals and health care facilities have taken precautions not only to preserve electricity to feed the critical equipment, including at least one computer to retrieve information.

 

Duplicate Documentation. Most health care facilities you see today have multiple computers near patient care areas, some even in the care rooms. For the facilities that do not have computers within a decent range of patient care, nurses have to use scrap paper or remember the information and then transfer the very same information to the computer for permanent record keeping. Transferring the information rather than simply inputting it directly to the computer can leave room for error.

 

Budget Constraints. As the nation faces financial troubles so does every aspect of consumers within it, including health care. Hospitals and other health care facilities continue to provide care for people even with the financial hardships. Computer technology advancement means out with the old, and in with the new. Replacing paper charts with computer chart systems means a lot of money being directed to do so. New computers, support techs, the systems themselves are all expensive and require maintenance, all of which take money to do so [3].

 

 

[1] University of Illinois at Chicago. www.healthinformatics.uic.edu

[2] United States Department of Labor. http://www.dol.gov/ebsa/newsroom/fshipaa.html

[3] “Electronic Health Records Documentation in Nursing” http://interruptions.net/literature/...formNurs04.pdf

[4] EMR & HIPAA. http://www.emrandhipaa.com/emr-and-hipaa/2010/06/08/think-about-the-problems-with-paper-charting/

 

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