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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
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Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
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Methods of Documentation VI: Case Management Model01:15

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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Issues And Trends In Healthcare Delivery System01:29

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The issues and trends in healthcare delivery are constantly changing. The COVID-19 pandemic is one recent issue that wreaked havoc on healthcare systems, causing a shortage of healthcare workers, high demand for medicines and supplies, and increased medical expenditure due to a lack of insurance. Other issues include rising healthcare costs and care fragmentation.
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Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
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Using an Evidence-Based Approach to EMR Implementation to Optimize Outcomes and Avoid Unintended Consequences.

Christopher A Longhurst1, Jonathan P Palma2, Lisa M Grisim3

  • 1Lucile Packard Children's Hospital and a Clinical Associate Professor of Pediatrics at Stanford University School of Medicine.

Journal of Healthcare Information Management : JHIM
|April 29, 2014
PubMed
Summary
This summary is machine-generated.

Implementing electronic medical record (EMR) systems with computerized physician order entry (CPOE) is crucial for patient safety. Local decisions during EMR implementation significantly impact quality improvement more than the specific system chosen.

Keywords:
CDSCPOEComputerized physician order entryEHREMRapplied clinical informaticsclinical decision supportelectronic health recordelectronic medical record

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Area of Science:

  • Health Informatics
  • Healthcare Management
  • Clinical Systems Implementation

Background:

  • Electronic Medical Records (EMR) and Computerized Physician Order Entry (CPOE) are vital for preventing medical errors and enhancing patient outcomes.
  • Healthcare systems are rapidly adopting vendor-based EMR systems, driven by economic incentives.
  • Evidence indicates that the success of EMR systems hinges more on implementation strategies than on the specific technology selected.

Purpose of the Study:

  • To highlight the importance of effective EMR implementation strategies.
  • To present an evidence-based approach for making EMR implementation decisions.
  • To offer a replicable framework for other healthcare institutions.

Main Methods:

  • This case report details a pragmatic, evidence-based approach to EMR implementation decision-making.
  • The methodology focuses on local implementation factors.
  • The approach is designed for adaptability and replication across different healthcare settings.

Main Results:

  • Local implementation decisions are the primary determinants of quality improvement performance in EMR systems.
  • The specific EMR product or technology is a less significant factor in achieving desired outcomes.
  • Effective implementation approaches are critical for maximizing the benefits of EMR systems.

Conclusions:

  • Successful EMR and CPOE adoption relies heavily on strategic, evidence-based implementation processes.
  • Healthcare organizations should prioritize local decision-making during EMR implementation to drive quality improvements.
  • The presented framework offers a practical model for optimizing EMR implementation and achieving better patient care outcomes.