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EHR and Nursing Practice



Introduction

The integration of technology into every dimension of health care has been crucial in promoting patient monitoring, assessment and eventually treatment. Most of the contemporary changes realized in nursing and the entire healthcare industry are due to technology. As a result, nursing informatics remains a key part of technology utilized by nurses in the course of healthcare provision. Furthermore, electronic healthcare records (EHR) has equally changed documentation of patient information as well as the overall provision of patient care. However, EHR fraud risks has emerged as a hot issue that threatens to render technology and informatics ineffective and inefficient in offering necessary patient care. In light of this, the paper involves the rationale for selecting the health IT topic of electronic health records, the arguments for its pros and cons, the informatics skills, conclusion and recommendations for the future. In essence, the integration of technology into every dimension of healthcare sector improves patient outcomes by ensuring efficiency is maintained.

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Health IT Topic: Fraud in Electronic Health Records

The significance of technology in the healthcare industry is mainly drawn from the overall movement from paper-based documentation to electronic documentation of patient records. Profoundly, electronic health records (EHR) is proving to be a significant addition to the quest for positive patient outcomes and eventually realization of quality care (Zuniga, Win and Susilo, 2010). Despite the importance of EHR, its impact on fraud risks and issues on nursing is substantial. Therefore, while deliberating on the topic of electronic health records, specific reference to EHR fraud risks and issues on nursing is worth exploring. Apparently, the selection of the topic of EHR fraud risks and issues on nursing is founded on the desire for an in-depth understanding of billing fraud and its effect on patient care and other related technologies in the nursing field. In other words, EHR deficiencies compound all the shortcomings in the use and suitability of technology in solving the numerous challenges in the healthcare sector.

Despite becoming the focal initiative in the movement experienced in the health IT movement, assessing the implementation and use of key technologies such as the EHR is essential in determining its use and the potential for better outcomes. Therefore, the potential for EHRs to provide affordable and sustainable health care to America’s surging population is limitless (Zuniga, Win and Susilo, 2010). In other words, significant challenges affecting the optimal use of EHRs should be addressed for the entire system to run efficient and effectively devoid of a substantial risk of EHR fraud and abuse. While all systems are not perfect, eliminating issues in the best humanly possible ways should be pursued, nonetheless (Zuniga, Win and Susilo, 2010). Notwithstanding the challenges, the role of the EHRs in providing quality care should not be misunderstood. Saving the healthcare industry of billions of dollars in the long run, improving efficacy and establishing electronic communication is equally essential.

Impact of Fraud in EHR on Nursing Practice

Health care records have a significant impact on any healthcare practitioner. Personally, an open avenue of fraud in the EHRs is actualized through copying and pasting. Commonly known as cloning, it involves allowing end users of the EHRs to select and replicate information from one source to another (Eardley et al, 2018). While most practitioners who partake in the activity cite saving time in writing documents electronically, this act leads to infiltration into other areas of the patient’s EHR. Infiltration is possible due to its use in scribing progress notes. It is also important to note that copying and pasting within the EHRs leads to end user neglecting to update crucial aspect of the copied text to fit the exact situation of the individual being described.

Copy pasting leads to an erroneous documentation of the EHR. It is based on the fact that scribing is consistent with a fraudulent insurance billing, particularly on entities like Medicare. Since most hospitals lack policies on copying and pasting within EHRs, ending the practice seems a long term. OIG reports that a paltry 24% of the hospitals have policies regarding the use of copy-paste while only 44% of the hospitals showed method of data entry on their audit logs when entering information on the EHRs (Eardley et al, 2018). A major disadvantage of the EHRs is their cost of adoption. Apparently, the cost of adoption is consistently aligned with time, money and dissatisfaction. Adopting EHRs and subsequent installation of a meaningful use system and training the end users on the software often proves to be costly and requires a significant time to attain efficiency.

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The cost of adopting the EHRs systems have significantly affected its use. As observed by Joudaki et al (2015) estimating the cost of EHRs range from $15000 to $70000 per provider. Furthermore, installation of the systems can potentially meet discomfort and discontent from the end users, such as nurses and physicians. Such negativity is often associated with the steep learning curve in the course of EHR adoption. Profoundly, end users often view EHRs as barriers to overcome as opposed to a tool for efficiency. Dissatisfaction with the tool has been observed by Joudaki et al (2015) as a key reason why it becomes easier to commit fraud. Since physicians consider it a stumbling block in realizing better healthcare, it therefore, becomes a liability on the path for its realization.

The substantial growth rate in the adoption of the EHRs is founded on the HITECH act of 2009. Since adopting EHRs was subsequently followed by eligibility of receiving $43,720 the transition was very first (Joudaki et al, 2015). In other words, a key advantage of EHRs is the fact that computerization of records means a possible demonstration of meaningful use, hence obtaining the financial incentive offered by the government. Such financial support can be directed to bettering service delivery through hiring more practitioners and ensuring that the facilities are in tune with the requirements necessary for positive patient outcomes and quality care (Eardley et al, 2018). With reference to documentation, the EHRs ensure that standardization is achieved, hence promoting standard record-keeping for the physician notes and the staff and the overall assessment of findings.

Elimination of fraud in the EHRs documentation is crucial in attaining its maximum use and further promoting patient welfare. Therefore, reduction of errors is one of the methods of realizing maximum use of the electronic health records. Reduction of errors is realized through computerization of physician ordering since it prevents misinterpretation of handwriting and transcription errors. Since EHRs have red flags when orders are incorrectly entered, efficiency is significant achieved. Understanding the importance of EHRs is further enhanced through focusing on its impact on security and privacy of the patients. Paper-based records provide an opportunity for more people to have access to the patient information (Eardley et al, 2018). Privacy breach is very much possible when paper-charts are sent to chart rooms or outside the facility. With information at the hands of the right persons, rapid treatment is possible thus emphasizing the importance of EHRs.

Nursing Informatics

In a dynamic modern world, the influence of technology is extensively observed in nursing work, hence the role of informatics. Therefore, in developing this assignment nursing informatics was relevant in providing access to a host of the information and data. This alludes problem solving skill, which forms a vital part of informatics. In light of the assignment, nursing informatics role in providing further education and knowledge was significantly reflected in the ease of access to trusted evidence-based information and other education tools. For instance, platforms like social media offer a wide array of healthcare information crucial for collaboration with other care providers (Eardley et al, 2015). Secondly, the interpersonal skills is another crucial role of nursing informatics relevant in the assignment. With new technology, it was possible to link up with clinicians, thus finding information about patient situations.

The ability to work with health data systems was an equally important skill within the nursing informatics that was relevant in the assignment. Having incredible knowledge in the data systems is crucial in working through the electronic health records, reading measurements, estimations and general processing of patient data. As previously observed, one of the requisite elements of technology is that practitioners are expected to go through a significant period of learning. Therefore, understanding how the technology operates with respect to specific devices is a key aspect that underlines the significance of nursing informatics (Joudaki et al, 2015). Communication is another informatics skills that was essential in the completion of this paper. Apparently, communication does not imply representing ones knowledge but equally listening to the contributions made by others as well.

Conclusions

Technology is transforming the healthcare industry by promoting the quest for positive patient outcomes and increasing quality care. Amidst the EHRs, the risk of fraud looms, particularly through copy-pasting among others. Even then, positives can be observed in saving the healthcare industry billions of dollars, improving efficiency, realization of meaningful use and increased collaboration based on better communication. Apparently, a future recommendation on the issue of fraud and overall use of EHRs concerns implementation of patient identity frame, which will validate the information entered by the nurse. It will imply that the right information is recorded each time. In addition, it is also vital to implement policies and procedures that will ensure certainty in the EHRs functions. For instance, it is necessary to put a system in place that will determine when copy and paste are acceptable and how often the EHR system will be audited. Lastly, it is crucial that review of the records is undertaken more often to detect discrepancies, changes and other errors. Essentially, all the changes should be focus on improving patient outcomes.

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