Health Information Systems plays an essential function in the Health Records Management. The aim of the HIS is to provide a balance between the rising number of patients and the demand to provide quality care. HIS is vital in helping patients to access their records through the introduction of new programs on electronic filing. HIS assist in enhancing the safety of private data for patients. The information ranges from prescriptions, addresses to the amount of data that is exchanged. The health information system is the one responsible for guarding patient information against unauthorized and security breaches.

HIS ensures compliance with the HIPPA regulations which provides particular data safety measures such as breach notification plan, disclosure policies, and data encryption.  Through the assistance of the HIS, the health informatics can analyze patient’s data and explore ways to improve on patient safety. Analysis of the health records improves accuracy since the Health Information Management team examines the files to check for errors or incomplete information.

Health Information System & Quality Care

Currently, HIS increasingly expand the ability to collect and stores patient’s data with the aim of improving care. Health Information Systems assist in collecting, compiling and analyzing data and also to communicate the result to health physicians to help in decision making. The HIS improves the access by a physician to lab reports hence reducing barriers in observations made by different health practitioners.

Modern medical systems encompass other individuals other than healthcare providers. The other individuals are the decision makers and policy makers. At an individual level, HIS supports the care of individual patients. The system allows for the provision of appropriate care to the patient at the right time by a qualified individual.  HIS reduces waste and significantly improves the quality of healthcare through personalized attention. The health facility focuses on collecting data on a system-wide level like medical errors, drug procurement, and medical errors.

HIS Effect on the Nursing Process

The nursing process assists an advanced nurse practitioner to contextualize, individualize and prioritize challenge areas. The steps in the nursing process encompass assessment, intervention, planning, nursing diagnosis, and evaluation. Biopsychological data on geriatric patients can be collected through direct observations, interviews and record views. A composite image of the multiple and competing needs of the informal caregiver and the geriatric patient can also be retrieved. Minimal data set is used in nursing homes to take assessment data as a means of treatment and care planning. HIS is also crucial in the Diagnosis stage where the information from the nursing assessments is used to examine the nursing problem and propose the nursing intervention. A refinement on the classification systems for NOC/NIC initiates the capture of nursing data.

The computer system can provide possible diagnoses for patients with specific signs and symptoms or retrieval and review of patients’ records. The HIS can be used in the planning process to recommend new interventions for the specific diagnoses and expected outcomes and also track increased patient outcomes. During implementation, the HIS system is used to record patient’s information and interventions like discharge guidelines and transfers. The system can also assist communication information through a computer-generated progress note which automatically sorts and prints data.  In the evaluation process, the HIS is used to compare large amounts of patient’s information and also to identify the outcomes that patients are likely to acquire. The HIS is essential in the recording and storing of data on observations, patients responses and nurse interventions.

Health Information System & Supporting a Culture of Safety

Several Information Management Systems (IMS) have a functionality that is specifically designed to enhance the ability of the nurse to issue safe patient care. The systems provide information on alerts of potential errors or interactions, required items to be documented and reminders on tasks. Nursing informaticists ensure that the HER system is well configured to maximize the safety elements of the system.  The system encourages patient safety culture by collecting, combining and analyzing confidential information stated by the healthcare providers. Patient Safety Organizations (PSOs) can use the system to identify problems and obtain possible solutions.

An example of a culture of safety is the Military Health System (MHS) enhance the safety of patients.  The HIS system collects proper information and data for patients that help in decision making. Electronic reporting of medical results for quick retrieval of data and sharing with other physicians is initiated through the HIS.  A computerized order system of data entry reduces the illegibility of problems. Finally, support decision systems are clinically used to prescribe drugs for patients. The system has properties that automatically secure logins and passwords which prevents other parties from accessing the network. The HIS improves the internet security of the different software used in health system records hence protecting the patient information from antivirus infection.

Human Factors that can lead to errors

Human factors in medical errors are common in medical practice. Common human errors are caused by the failure to observe procedures and policies intentionally as an act of positive deviance or just unintentionally as a result of an oversight that results in an error. Other human factors familiar with medical practice encompasses interruption and distraction. Studies have reported that an average of 6.7 interruptions at work per hour is experienced in medical administration. A system fallibility issue is an example of a comprehensive human factor perspective which is a structural design-related problem.

The root cause of the problem is as a result of architectural issues or equipment challenges. Another human factor is the user error which is common, and the solution is to design a medication administration using an electronic dispensing and bar coding which is used to limit the risk for occurrence of the error. System challenges result in the frustration of the nurses which leads to mistakes. Cognitive or awareness issues are also significant aspects of human errors in health care.  Situation awareness is used to assist with decision making and to comprehend better how they are created into human fallibility as a precursor to errors.

CDS (Clinical Decision Support) alerts

Clinical Decision Support (CDS) is any tool that issues administrative staff, patients, clinicians, and caregivers or other care team members with information that is filtered or targeted to a particular person or situation. CDS functions to enhance quality care avoid adverse events and allow members of the care team to be more efficient.  The modern CDS aim at providing IT health applications, analytics, and modules that leverage the significant data assets of an organization. For providers and the HER incentive programs, it provides individuals involved in care processes with a piece of comprehensive and person-specific information. The “return to clinic” reminders present in the EHRs remind front desk staff to call patients who should receive routine screenings. The calls are meant to tell them of upcoming appointments or authenticate pre-visit preparations.

Health Information systems are designed to improve clinical decision making. The function is supported by its ability to address the rising information overload that nurses face. The CDS provide a platform for integrating evidence-based knowledge into the process of care delivery. When clinical nurses can obtain the right information at the right time, the clinicians will be able to make correct decisions on patient safety.

HIPAA Security and Privacy Rules

HIPAA security rules develop a set of security standards for the protection of essential patients information. The patient information is often being housed or moved in an electronic form. The HIPAA was established as a flexible extension to the protections in the rule. Healthcare providers use the HIPAA in medical billing, electronic health records, and coding software. To properly manage risks, the security rule has authorized all covered entities to follow security guidelines to keep their practices in check.

A common feature of the HIPAA is the risk analysis which is a record review that tracks access to electronically stored information, evaluate potential risks and assess measures on securities. The HIPAA privacy rule develops standards to protect data on patents held by the entities and their business associates.  The security rule identifies and protects against confidentiality.  For the privacy of the patient the security, the rule recognizes and protect impermissible disclosures and uses. The security rule also ensures compliance by the workforce to promote quality of care.

Evaluation of Technologies (Part 1)

The current technology in medical practice is the Electronic Medical record or sometimes called the Electronic Health Record (HER). The EMR is interlinked between facilities and be examined from outside using the internet through wireless technology.  The EMR has potential capabilities such as assisting health physicians in checking medical record with just a touch or a click on the mouse. Clinical data can be automatically linked to the medical record of patients when uploaded to the diagnostic lab server.  The inbuilt database assists physicians to make evidenced-based decisions through the Clinical Decision Support (CDS) system. The medical conditions which are reportable on the government can be transmitted automatically. Prescriptions are created by choosing from a top-down list that prevents medical errors.

Digital Ink is a technology that permits writing on a screen and has currently being integrated into the EMR system. An example of such a technique is Microsoft Ink. A charting system can allow stylus input and convert it into text. Among some of the uses encompasses drawing images like surgery to communicate between the patient and the doctor. The system can be used to annotate diagnostic images like X-ray, and MRI scans to identify critical features. Digital Ink inputs text naturally in situations where the patient is unable to communicate but can write a note to a doctor. The system also authenticates reports tremendously by placing signatures.

Evaluation of Technologies (Part 2)

The MicroMD EMR software system is vital in fully accommodating aspects of clinical workflow.  With the EMRs patient data is assesses and the safeguards assist in preventing medical errors. The system can integrate a universal nursing language, and nurses can hence document the nursing care they give to patients. Staff buy-in promotes the attitudes and expectations of the health informatics.

Health informatics that might have issues with data entry on computer systems can use the Digital Ink on paper.  It involves the use of paper and pen for recording clinical data in a clinical setting. Pen and per are used to collect rough data and later transferred into other health information system. The digital pen has a camera that records the pattern of writing on a digital paper.  After registering, a cradle is used to transfer the data to information systems. The primary significance is that health informatics who cannot afford using the computer system can apply Digital Ink.

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