Thursday, February 3, 2011

Module 2 Healthcare Information and Devices

What is one way you could become involved in designing, selecting, evaluating, or implementing an information system in your workplace?

I have actually done this already. The department in which I work has an outpatient program where we monitor patients who are at home on either enteral or parenteral nutrition. We watch labs, provide phone calls, and sometimes have patients come in for a clinic visit. We often make changes to their regimen based on observed or reported data and information. 
Prior to when I started my job, the charting for these clients was done on paper. We had large bulky charts with hand written clinic notes, medications, notes from phone calls and tracking sheets for laboratory data. I am not a paper person, so I implemented the use of a pre-existing information system available at my facility to store free-text progress notes, assessments using templates and clinic visits using a SOAP form with areas to enter height, weight and other vital signs. The SOAP form also pulls in medications, problems and allergies entered by other providers, making med-rec a quick process, as well as flagging drug interactions when we prescribe new medications for our patients. The laboratory and radiology data have always been available in this computer system.
Unfortunately, while I have made a brave start, there are people in my department who won't "let go" of their paper - every clinic note and phone assessment now gets printed and put into the bulky patient chart, as well as being available in the computer. We are also still transcribing lab values and radiology information from the system into the paper chart.
In addition, we have demographic sheets in the charts with basic patient information, names and phone numbers for other providers, access device and current nutrition regimen. I have been trying to convert this to an electronic record for a year - the information on the paper gets crossed out, whited out, written over until it is often illegible, and we have no way of tracking history of nutrition regimen or access device. I tried making an excel worksheet but it still didn't fit my vision. I would rather use database software - but I need to get access to the software and help building a secure database. My preference would be to get a practice management system, but I haven't managed to sell that to my supervisor - the cost is a big factor there.
My vision is still a work in progress, andI am leaving my current position soon. I am not sure where the department will be in the future, but my hope is that I have planted the seed that there are better and more efficient ways of harboring patient information that bulky paper charts!

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