This paper examines the transition from paper-based to electronic health records within a healthcare organization that adopted the PharMerica paperless administration system. It discusses the benefits of computerized physician order entry (CPOE) and related clinical applications, including real-time record access, improved medication accuracy, and reduced administrative burden. The paper also addresses challenges such as privacy violations, data entry errors, and the importance of staff training and organizational buy-in. Compliance with HIPAA Privacy and Security Rules is highlighted as a key component of implementation. The paper concludes with a commitment to continuous process review and technology-driven improvement in patient care outcomes.
The days of paper-based records in health care are fading. It is widely believed that the broad adoption of clinical applications such as computerized physician order entry (CPOE) can lead to major healthcare savings, help eliminate medical errors, and improve healthcare outcomes for patients (Lynn, 2011). Because of such benefits, the Obama administration included automated adoption in health care as part of its overall agenda, calling for "the immediate investments necessary to ensure that within five years, all of America's medical records are computerized" (Obama, 2009).
Our organization moved to PharMerica's paperless administration system after a careful analysis and assessment of the best solution for meeting the organization's specific clinical and business needs. The new clinical system eliminates the need for peel-and-stick labels, faxes, handwritten documentation, and manual processes. The outcome has been improved workflows and overall patient outcomes. By turning to technology, we have been able to extend health information technology into the realm of patient record keeping and automated healthcare processes (Kumar & Aldrich, 2010).
Today, a patient's entire medical history can be converted to digital format and stored securely for use by various entities over time. This has allowed us to eliminate massive paper trails, condensing relevant information into electronic form. Records are easily retrievable and enable patients to navigate the healthcare and pharmaceutical system in a safer and more efficient manner (Lynn, 2011). There is a higher level of standardization, security, and improved privacy for patient information.
The PharMerica system allows us to work with new patient information as well as older records — generally pre-2000 — which have been scanned and stored in graphic format or as Adobe PDF documents (Gagnon et al., 2010). This includes X-rays, test results, prescription histories, ultrasounds, and MRIs that were formerly recorded by hand and were often illegible and subject to fading and damage over time (Kumar & Aldrich, 2010). Records are updated in real time for immediate access, which has meant an improved ability to manage more patients more efficiently (Lynn, 2011).
Some of the primary elements of the PharMerica system include computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. Eliminating manual processes in these areas has truly helped improve healthcare delivery; however, there are still areas that require a great deal of monitoring for human and data entry error. Privacy violations have at times resulted from non-designated users gaining access to confidential patient information. Records have at times been assigned to the wrong recipient. Little to no proofreading of entered data has led to misidentification of medication in some cases.
Our organization has addressed these issues by requiring extensive staff training in the proper use of critical technical systems and by conducting routine needs assessments to identify technical vulnerabilities and address them proactively. The broader challenge of overcoming barriers to electronic medical record (EMR) implementation is well documented in the literature and remains a key concern for healthcare administrators nationwide (Kumar & Aldrich, 2010).
"Mandatory training, focus groups, and change management"
"HIPAA rules, clearances, and system security protocols"
"Improved patient outcomes and commitment to ongoing innovation"
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