The current paper is aimed at introducing a new electronic medical records system (EMR). It is necessary to define the system, it is best made by Davidson (2009), who provides us with a clear explanation of what the EMR system is: “EMR is the over-reaching concept of taking all medical information, including hand-written doctor’s notes, medical records, x-rays, test results, surgical video, audio, prescriptions and any other patient information and storing it in an application that organizes it and makes it instantly available to medical providers.” (p. 15).
There are the main issues that I would like to discuss during the current paper. Namely, the importance of access to information, especially with regard to the patient’s privacy and possible types of security measures. In addition, it would be useful to touch upon the ways that Quality Improvement (QI) data can be collected from the system and used to identify the occurrence of problems and errors. I am also going to focus on the roles of the implementation team while introducing the new electronic medical records system.
It is really important to update the records in time because poor handwriting, inaccurate data in the scripts, and other details may influence the quality of the nursing care provided to the patient. As suggested by Doyle (2006), “Improve the effectiveness of communication among caregivers—Health care providers easily can document and access patient information in the EMR, which should include the most accurate and timely information about patient status and nursing care.” (p. 1336).
The privacy of personal information is absolutely safe because “…computer use may benefit health care by improving the entering and sharing of data” (Beiter et. al, 2008, p. 222). However, personal health information becomes more vulnerable to breaches in confidentiality. As some personal information about the patient is included in his/her personal health record, it is necessary to prevent breaches in confidentiality.
As the security measures are of great importance for the privacy of the patients’ status, health, medications prescribed, symptoms, and diagnosis, it is necessary to incorporate the most appropriate security measures allowed by the legal power. The security measures for personal health records include software programs that are aimed at preventing breaches in confidentiality.
Moreover, it is necessary to indicate that most nursing staff members and other care providers have free access to the patient’s data which makes it inappropriate to report, whereas each staff member can find all necessary information in the database. The errors that occur should be corrected in order to ensure the normal operation of the system. When the medical staff faces some problems concerning the operation of the system, it is necessary to provide them with appropriate information and training on the work with this system.
The first step that should be made by the implementation team is to inform the staff of the medical institution about the necessity of providing changes in the form of new technologies. The second step is to incorporate the new utility into the operation and make sure all software bases are appropriate and work to the full capacity. The third step is to implement the guidance about the new technological innovation in order to teach the medical staff to work with the new records system. The fourth step is to analyze different mistakes and difficulties in the operation and maintenance of the new system. Evaluation of the fifth step presupposes that the implementation team should make sure that the staff is coping successfully with the new technology with the help of surveys conducted. The fifth step includes inferring and further work with the medical staff.
Reference List
Beiter, P. A., Sorscher, J., Henderson, C. J., & Talen, M. (2008). Do electronic medical record (EMR) demonstrations change attitudes, knowledge, skills or needs? Informatics in Primary Care, 16, 221-227.
Davidson, J. (2009). Electronic medical records: what they are and how they will revolutionize the delivery of resident care… first of a two-part series. Canadian Nursing Home, 20(3), 15-18.
Doyle, M. (2006). Promoting standardized nursing language using an electronic medical record system. AORN Journal, 83(6), 1335-1348. ISSN: 0001-2092.