Implementation Of Electronic Clinical Documentation In D.W. McMillan Memorial Hospital

Discuss about the Implementation of Electronic Clinical Documentation.

Informatics plays a significant role in the modern business services and applications. There are numerous sectors and industries that have applied informatics in their processes and have benefitted from the same. The essay deals with the use, application and implementation of informatics in D.W. McMillan Memorial Hospital. It covers the introduction to the hospital along with the goals and challenges associated with it. A detailed application of informatics to the organization along with the various phases under it has been covered in the essay.

D.W. McMillan Memorial Hospital is a community hospital that is located in Brewton, Alabama and has a capacity of 49 beds. The hospital is governed and managed by governed by the Escambia County Healthcare Authority Board of Directors. It is running successfully since over sixty years and aims to provide the excellent health care services to the individuals (Dwmmh, 2017).

The hospital aims to provide the excellent quality health care services to the individuals. In addition to the same, it also aims to manage the information associated with the patients as well as the staff members in an integrated and secure manner. Providing health education to the citizens is also one of the goals of the hospital. The hospital is aiming to manage the health information of the patients with the aid of Electronic Health Records (EHR) to achieve its goals (Griffin, 2014).

There are a number of challenges that the hospital goes through in the implementation of any of the new technologies. The case is the same with the implementation of Electronic Health Records. The major challenges are associated with the lack of resources, lack of skills along with the issues in the project management and change management (Norris, 2002).

D.W. McMillan Memorial Hospital was one of the early adopters of EHR. The need and decision to implement EHR in the processes of information storage and management was done after an extensive research that was carried out by the senior management of the hospital. Planning of the project was done at D.W. McMillan Memorial Hospital by analyzing the problems with the current system, finalization of scope, decision of the project approach along with the resources and their skills (Moen, Merete and Knudsen, 2013).

The process of application of EHR in the hospital was decided to be done by developing an automated replica of the existing paper based processes. For instance, the workflows were designed by analyzing the paper based for a particular health condition, such as, pneumonia care and an electronic version of the form was designed and implemented.

Discovery and Representation

The language options that were selected in the application of informatics to the hospital were kept in accordance with the general language trends in Alabama. The HER implementation was done in English as the major language and there were customization options that were provided in terms of language with the options as German, Spanish and French (Herrick, Gorman and Goodman, 2010).

Communication between the project team and the stakeholders is extremely necessary and it was made sure during the EHR implementation at the hospital that the requirements and specifications were clearly understood by all. The management adopted a phased approach in the project to make sure that the team had the sufficient time to accomplish the implementation and application activities. Also, any of the errors, conflicts and disputes were reported and resolved by the leaders and managers (Kim, 2012).

Discovery in a project or an activity refers to the knowledge that is gained through the same. Discovery plays an extremely significant role as it is necessary for every activity to give away certain learnings and knowledge to the resources.

In the implementation of EHR at D.W. McMillan Memorial Hospital, Information Systems (IS) and Information Technology (IT) and their concepts were not regular processes that were followed. The resources that were present in the hospital did not have any prior experience on the usage or the implementation of EHR in the hospital. The design and implementation team therefore referred to the existing paper based system to understand the requirements and came up with their automated counterparts (Payne, 2013).

The integration of the system components with each other was one of the major discoveries during the process. It was discovered that there were various health conditions that shared the same form structure and it was possible to keep certain details of the patients as generalized as they were mandatory in all the health conditions.

Electronic Health Records make use of the computing resources for the transmission and storage of health information. For the recording the health information of the patients in order to apply informatics in the process, it was required to have a back-end for the purpose. The health information was recorded with the aid a front end and the information was stored in the database (DB) linked with the same.

There were many challenges that D.W. McMillan Memorial Hospital went through in order to manage the project and the changes that resulted out from the same. It was difficult for the hospital staff o get used to the system. Therefore, a training plan was design for the successful application of informatics (Savel and Foldy, 2012).

Recording and Remembering

D.W. McMillan Memorial Hospital came up with the development of a four session training program for the nurses that were appointed by the hospital. The admin or the super user and the instructors used to work with a group of eight nurses during the training sessions to provide them with the practical experience of the system. The hospital also developed a series of simulated patients in order to allow the nurses to gain experience with the real-world scenarios. Since the structure of the group was kept small, it provided the nurses with the ability to gain a better understanding and also allowed them to get answers to their doubts and queries easily. There was also feedback sessions that were arranged to make sure that the teaching covered during the trainings were remembered (Lovelace and Shah, 2016).

The training plan and structure for the physicians was designed and structured in a little different manner. One-on-one education was provided to the physicians in the presence of a group. There were eighteen physicians grouped with eighteen super users and the training was provided to them all at the same time. Physician training was structured a bit differently, offering one-on-one education in a group setting. It allowed the physicians to gain complete knowledge about the system and the focus of the super user was also laid on one physician at a time.

Data modeling played a significant role in the structuring of the information that was being stored in the electronic format.

The use of data structures and database made sure that the health information was being recorded and stored in a systematic manner. The health records for every patient were kept separate and were identified with a unique id assigned to each record. It was also made sure that the health records associated with a particular professional or provider or health plan or health condition was constructed in a manner that it could be easily retrieved using any of these parameters (Lavin, 2015). 

Conclusion

Informatics plays a significant role in the modern day businesses. It is necessary to have automated tools and applications for the easy processing of the information along with easy storage and retrieval of the same. Informatics has several applications and health care sector is one of the prime applicants of informatics. Health services are required to be of the latest technology and quality for every health centre and hospital to make sure that timely care is provided to the patients without any compromise on the quality. Electronic health records are easy to manage and maintain and also give various advantages such as prevention of data loss and leakage, removal of data duplication and faster processing of the data. D.W. McMillan Memorial Hospital, Brewton, Alabama applied informatics by carrying out a successful implementation of EHR in its processes and applications. The implementation process was successful as there was adequate planning and control that was involved in the project. Also, the step by step process was followed for the application of informatics by focusing upon naming and knowing, language and communication, discovery and representation, recording and remembering along with systematization and construction. The project went through numerous challenges due to the lack of resources and skills along with the need to manage huge number of changes. However, the business goals of the project were achieved through correct project approach along with the mix of technology and human skills. Use and application of informatics at the D.W. McMillan Memorial Hospital allowed the hospital to not only provide enhanced service quality but also enabled the hospital in providing health education to the citizens. The data that was collected and stored through EHR system was analyzed to understand the health patterns on the basis of a number of different factors and suggestions were accordingly provided to improve the health condition (Mo, 2013).

References

Dwmmh, (2017). D.W. McMillan Memorial Hospital. [online] Dwmmh.org. Available at: https://www.dwmmh.org/ [Accessed 25 Mar. 2017].

Griffin, C. (2014). EHR implementation in a smaller hospital: A case study. [online] EHRIntelligence. Available at: https://ehrintelligence.com/news/ehr-implementation-in-a-smaller-hospital-a-case-study [Accessed 25 Mar. 2017].

Herrick, D., Gorman, L. and Goodman, J. (2010). Health Information Technology: Benefits and Problems. [online] Available at: https://www.ncpa.org/pdfs/st327.pdf [Accessed 25 Mar. 2017].

Kim, K. (2012). Benefits of and barriers to the use of personal health records (PHR) for health management among adults | OJNI. [online] Ojni.org. Available at: https://ojni.org/issues/?p=1995 [Accessed 25 Mar. 2017].

Lavin, M. (2015). Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings. [online] Nursingworld.org. Available at: https://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-2015/Articles-Previous-Topics/Technology-Safety-and-Professional-Care-Documentation.html [Accessed 25 Mar. 2017].

Lovelace, K. and Shah, G. (2016). Informatics as a Strategic Priority and Collaborative Processes to Build a Smarter, Forward-Looking Health Department. [online] Available at: https://journals.lww.com/jphmp/Fulltext/2016/11001/Informatics_as_a_Strategic_Priority_and.16.aspx [Accessed 25 Mar. 2017].

Mo, P. (2013). The Use of Internet for Health Education. Journal of Biosafety & Health Education, 01(01).

Moen, A., Merete, L. and Knudsen, M. (2013). Nursing Informatics: Decades of Contribution to Health Informatics. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3717442/ [Accessed 25 Mar. 2017].

Norris, A. (2002). Current trends and challenges in health informatics. [online] Available at: https://pdfs.semanticscholar.org/a8c1/d4b21e8ea4c247a50b568adcb33a267235f8.pdf [Accessed 25 Mar. 2017].

Payne, S. (2013). The Implementation of Electronic Clinical Documentation Using Lewin’s Change Management Theory | Canadian Journal of Nursing Informatics. [online] Cjni.net. Available at: https://cjni.net/journal/?p=2882 [Accessed 25 Mar. 2017].

Savel, T. and Foldy, S. (2012). The Role of Public Health Informatics in Enhancing Public Health Surveillance. [online] Cdc.gov. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/su6103a5.htm [Accessed 25 Mar. 2017].