The ‘health record’ is the principal repository of an individual patient, and advancements in information technology and the emergence of electronic medical record systems revolutionized health records management. Health information management (HIM) professionals serve the healthcare industry and public by “managing, analyzing, and utilizing the data vital for patient care and making the data accessible to healthcare providers” and quality patient care refers to all the activities related to managing the healthcare services provided to patients (Johns, 2006, p.xi). Preventing morbidity, the state of being diseased, due to an infection is an important ‘quality management function’ and the healthcare information derived from healthcare records assists health information managers in formulating strategies for ensuring quality healthcare (Loretta, 2004, p. 98).
The internet and wireless communication present exciting opportunities for process engineering in support of care delivery for the HIM professionals as it eases manual information transfer and decreases organizational costs. Appropriate database management software application and database technology for collection, storage, and retrieval of healthcare data will support ongoing quality assessment of a healthcare organization, and it emerges that wireless network is cost-effective to provide seamless access to patient records to clinicians, and thereby reduce medical errors.
The ‘health record’ is the principal repository (Storage place) for ‘data’ and ‘information’ about the healthcare services provided to an individual patient, which has diverse names, such as ‘patient record’, ‘medical record’, resident records, ‘client record’, etc., and every time a person consults a new healthcare provider additional health records are created. The primary purposes of health records are associated directly with the provision of patient care services, and it is classified into patient care delivery, patient care management, and patient care support process.
Since electronic health record (EHR) helps physicians, nurses, and other clinical care professionals make informed decisions about diagnosis and treatment; facilitate effective communication amongst caregivers; allow healthcare providers to assess and manage risk, and represent legal evidence of the services received by the individual patient it ensures qualitative and effective patient care delivery
Importance of health records data in quality management
Increase in aged care patient population, escalating health care costs, shortage of trained health care manpower, and demand for improved quality in healthcare at reduced costs, pressurize every healthcare provider to improve health care delivery system through assimilation of modern technological innovations of computers and electronic gadgets. Access to patient records on time is crucial for initiating fast and timely diagnosis and treatment, and slow access with incomplete data may increase the likelihood of medical errors and create havoc in patient outcomes and hamper the quality of care.
It is experienced that lack of integration in computer networks and databases and archaic and inflexible technology infrastructure impedes in patient’s expectation of best possible healthcare from their providers. Advancements in information technology revolutionized health records management and introduced interactive ‘electronic health records (EHR) systems that have become part of the national agenda in the United States (Johns, 2006, p.25). As EHR helps reduce healthcare costs, improve care, and avoid medical errors, President George W. Bush has outlined a plan to achieve EHRs for most Americans by 2014. It is envisaged that an effective documentation procedure using computers and digital devices will replace paper-based health records.
Healthcare quality management activities
“An integrated quality management system provides an opportunity to deliver consistent, high quality, and cost-effective health care in any health care organization,” which simplifies the mandatory accreditation process (Berte, et al, 2004) Understanding and documenting the healthcare delivery process of an organization, training people competent in adapting those processes, identifying problematic process, and improving processes where problems exist are basic tenets a committed healthcare organization to reduce medical errors, and thereby ensuring healthcare quality.
Different stages of quality management are quality control; quality assurance; quality management system; quality cost management; and total quality management, of which quality management, the systematic process-oriented approach to quality objective is a major level in the healthcare quality hierarchy. Clinical quality management usually includes three related processes: clinical quality assessment, utilization management (UM), and risk management. Clinical quality assessment helps determine the utility of services provided to patients according to predetermined standards of care. Utilization management is a group of processes used to measure the efficient use of resources by the healthcare organization. Risk management oversees the medical, legal, and administrative operations within a healthcare organization for minimizing the organization’s exposure to liability claims (Johns, 2006, p.499-500).
Quality management is adapted as a ‘cross-functional program’ and a multidisciplinary committee comprising medical staff, nursing staff, and infection control team as well as appropriate representatives coordinate the program and ensure the consistency of the clinical quality assessment process (Johns, 2006, 515). Easy and speedy access to healthcare information is paramount for the successful implementation of quality healthcare, and an electronic medical record (EMR) is the only alternative to achieve this goal.
Emerging technologies in record management
“To reduce errors and improve quality in an increasingly demanding delivery environment, healthcare organizations need to transform inherent business processes and infrastructure” (What makes you special, 2007, p.6). Emerging technologies focus on how wireless networking helps with the continuity of care, quality of care delivery, minimizing of risk for a facility, and can be supported and/or incorporated by the total cost of ownership (TCO).
The preliminary stage to implementing an EMR system is evaluating a facility’s current infrastructure preparedness. Establishing the facility’s infrastructure and technology baseline encompass PCs, servers, network hardware, application licensing agreements, network wiring, electrical wiring, and IT support operations available, and upgrading these to be comparable with the new EMR system. At this juncture Sainte-Justine Hospital, Quebec gives a model for the successful implementation of an electronic medical record system.
Sainte-Justine Hospital, the largest hospital network of a pediatric hospital in Quebec, providing care for 20,000 patient visits a year, had encountered a problem in integrating patient information between its networks. The health system engaged IBM to build a “customized electronic health record system that would integrate information between Sainte-Justine Hospital and two other hospitals in the network.” (What makes you special? IBM health network solution, 2007, p.6).
The project adopted IBM Health Network Solution (HNS), and implemented the first customized electronic health record system in Quebec, which helped consolidate dissimilar information into a single patient view. It helped the Sainte-Justine Hospital network to accelerate data access by making the medical records readily available to its healthcare professionals via a Web interface, and thereby improving patient care. It was found that by converting from paper to a computer-based health record format patient testing duplication was eliminated with an expected cost reduction for lab and radiology tests by 15 percent. (What makes you special? Innovation for healthcare providers, 2007). Other products that made the computerization project in ‘Sainte-Justine Hospital’ a success were IBM DB2, a next-generation hybrid data server; IBM Lotus Notes, a premier integrated desktop client option; and IBM WebSphere.
It may be concluded that it is essential for a project manager to be able to understand technological components and healthcare needs to plan and manage the major initiative being undertaken at the facility. Ultimately, adhering to the fundamentals of training, communication, and support is crucial for the successful implementation of the project, and establishing a quality management process in a healthcare organization.
Berte, L.M. et al. (2004). A quality management system model for health care approved guideline—second edition. NCCLS document HS1-A2, (24(37). Web.
Johns, M.L. (Ed). (2006). Health information management technology (2nd edn). Illinois: American Health Information management Association.
Loretta, H.A. (2004). Calculating and reporting healthcare statistics. Illinois: American Health Information Management Association.
What makes you special? (2007). IBM Healthcare Catalog: Canada2007. 2. Web.
What makes you special? Innovation for healthcare providers. (2007). IBM Healthcare Catalog: Canada2007. Web.
What makes you special? IBM health network solution. (2007). IBM Healthcare Catalog: Canada2007. 6. Web.