Sample Capstone Paper: Health Information Management

What is Health Information Management (HIM)? What is the Role of Health Electronic Records in HIM Nowadays?

Introduction

Health Information Management (HIM) is an important practice in the health sector. Managing health information plays a major role in ensuring that records are properly stored and can be retrieved whenever required by relevant authorities. In the past, HIM entailed the use of traditional paper work, in which patients’ health records were stored in hard copies. However, paper-based Health Information Management has since been replaced by the electronic system with a view of increasing efficiency. Research indicates that lack of proper health management system by various health institutions leads to many unnecessary deaths. According to the Institute of Medicine, almost 100,000 patients die annually in the US due to lack of complete patient information (Valerius, 2007).
It is obvious that lack of proper information system has contributed to the poor quality of the health care given to patients. For this reason, this paper seeks to design an appropriate Health Information System that utilizes the electronic platform. This HIM is meant to come with an appropriate Electronic Health Record (EHR) that is able to capture all the relevant patient information. This system should have the ability to perform activities like billing, documentation, patient registration, administrative staffing, to name but a few. However, the major focus of this design is on the HER, patient portals, and medical practice management.

Background Information

The use of the traditional paper-based health information system has been found to affect quality health care provision in many institutions. This comes with the difficulty in compiling all information of an individual in a system where it can easily be retrieved. Furthermore, medics easily make mistakes that lead to death, mostly contributed by the errors. There has been an increased need to revolutionize towards the electronic health record system as research from medical practitioners has approved. According to Wall Street Journal (2010), 89 percent of the US public believes that the Electronic Health Record keeping is better as it provides more benefits than the privacy risks raised by others.

The ability to access full medical information of patients helps caregivers follow appropriate treatment in each case. Lack of relevant background information on each case may lead to misinterpretation and wrong decision-making. Health Information Management problems are compounded by the fact that electronic as well as paper-based information on different patients are scattered in different health institutions, having no single platforms that shares the information.

For this reason, a secure Electronic Health Record (EHR) remains an important infrastructure that will help provide adequate health care services to patients. Many lives will be saved, as medics will easily access relevant information to help manage medical practice (Valerius, 2007).

An appropriate HIM should be able to enable collection, use, storage, and transmission of information that meets legal and ethical requirements in health care provision. In order to achieve this, it has been found that individual institutions have to put in place systems that can collect and manage the data in a way that problems can easily be identified through the same (Stansfield, 2005). This is an important fact that can help discover appropriate actions to be taken in each case.

The above analysis indicates that all relevant institutions must embrace transition from paper-based health information management into an electronic platform. This proposal seeks to have a system with relevant information that can be easily acquired by health providers whenever needed.

Aims and Objectives

The following are the aims and objectives this will be achieved after the development and design of this Electronic Health Record (EHR) system.

• An improvement of quality care services through automated advice and relevant patient registries.
• Improvement of coordination in health care provision
• Engagement of family members in helping to provide health care
• Provide the required security and privacy for all the patients.
• Improve the general public health through reporting of important information like immunization.

Electronic Health Record Design

It is important to note that Electronic Health Record system is not just a simple application meant to be used but institutes a number of systems that are integrated in a way to achieve the required goals and objectives. Coming up with such a system requires adequate time and money. This electronic system will be able to document health details of all patients who receive services at the health institution. In summary, Electronic Health Record will be able to capture demography of the patient, medication progress and the related allergies, lab results, immunization, and private details like and weight. In essence, this system will provide data that will be important in making important clinical decisions by the medics.

Nature of the Record

In order to come up with organized and quality records, the system will be designed to have patient health record where clinical database of individual patients will be entered. This record will have office records, general evaluations, and any other relevant information generated from direct interaction with any health care professional. Primary patient record will entail records of personal observations by health professionals. Another important record will be known as the secondary patient record. This will only have selected data that can help non-professional caregivers to do their work. At this section, other support documentation like administration and payment will feature.

To ensure quality, Electronic Health Record system will ensure that accuracy is maintained through accurate and valid data entry. Accessibility of the stored will also be an important thing, as it will ensure that lawful exchange of the same. The information within the system will also be consistent to ensure that sameness is maintained across the board. The ability to update the information in the system will help maintain its quality and authenticity.

A system that does not show the current information may lead to the wrong decision on a given situation. In order to make appropriate decisions, comprehensiveness of the data in the Electronic Health Record system will be of importance. Inconsistent data may lead to the wrong outcome and consequent error in terms of appropriate care and medication to a patient (Valerius, 2007).

Core Components

The proposed Electronic Health Record system will have the following components: electronic content management system that will allow for the storage and personal health records. The system will also have a clinical decision support to help medics apply the correct care, a computerized order and electronic prescribing to help speed up delivery of necessary care. The system will be able to generate prescription necessary prescriptions and transmit them electronically. Another important component of the EHR system includes a patient portal where health information exchange can be done.

Medical practice is an essential part of care giving because medics can only appropriate decisions depending on the information that is available on a given case. For this reason, the system will be able to maintain a list of the present diagnosis in order to update the medics and avoid errors. This means that the system will be able to inform caregivers on the urgent cases to be worked on. On the same note, the system will also indicate the current list of medication, including special occurrences like allergic reactions. Recording and charting of the changes in the health condition will be an important component of the system as it will be able to indicate the improvements made during the treatment.

To achieve the intended goals, collection of information will be aided by the computerized programs from different departments of the health institution. For instance, departments like pharmacy, lab, point-of-care documentation as well as finance will be able to use the system to retrieve and input relevant information of the patients. Health records will thus be stored in an electronic format, unlike the traditional paper-based files that were kept in the health information department.

In cases where hard copies will be inevitable, the scanning and appropriate indexing will be done to enable appropriate electronic storage. The software will have Computerized Patient Record System (CPRS) interface with ability accept appropriate images that can be shared. However, hard copies will have to be discouraged because they are prone to errors. Errors can arise at the point of manual entries and when doing the indexing into the electronic storage, especially where no bar codes are available. For this reason, the hard copies will have bar codes to help in identification and automatic electronic placement to avoid human errors…

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