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Medical record

Health Information Management

However, despite the potential benefits of implementing an EMR, the adoption of this technology has been slow. There are many potential barriers to the implementation of an EMR with the most salient being poor change management.

This article presents a theoretical discussion of how a combination of these two theories could be applied in practice to successfully implement an EMR. Building a Safer Health System has been to move toward the adoption of an electronic health record EHR as a means to transform health care and improve patient safety Pomerleau, The goal of an electronic health record that connects care providers to patient information nationwide has permeated the Canadian health care system as well, but before a national EHR can be realized, health regions across the country need to implement an electronic medical record EMR.

Yet despite these benefits many health regions are slow to adopt this technology Wolf, One of the reasons for this slow adoption may be that reports show up to 50 per cent of attempts to implement health information technology HIT initiatives fail McLane, Barriers to the successful implementation of an EMR identified in the literature include: Change management is about engaging and preparing people.

It is about behavior change, maximizing Medical record, and achieving results. It is about identifying and anticipating barriers and creating strategic solutions. Building a Safer Health Medical record details shocking statistics that at least 44, people, and perhaps as many as 98, people, die in hospitals each year in the United States as a result of preventable medical errors.

These errors have been linked to system issues that lead people to make mistakes or fail to prevent them, versus poor care from individual providers IOM, System issues that have been implicated include: One of the primary Medical record to improve patient safety is to reduce the risk of adverse drug events, and one strategy for reducing that risk is to implement an EMR CIHI, What is an EMR?

An EMR is designed to replace the traditional paper medical record, and at its most basic level, provides a legible, organized method of recording and retrieving patient information.

However, an EMR is more than just an efficient electronic filing system for patient records. An EMR can include patient safety and provider support features such as computerized clinical decision support CDScomputerized provider order entry CPOEelectronic medication administration record eMARand electronic medication alerts, just to name a few.

However, despite the evidence to suggest that implementing an EMR may reduce system inefficiencies that are contributing to adverse events, the adoption of this technology has been slow, and many attempts to implement change have been unsuccessful McLane, ; Wolf, Barriers to Implementation Barriers to successful implementation of EMRs identified in the literature include: However, considering that attempts to implement EMRs continue to fail despite the commitment of serious financial resources McLane,I would suggest that the most significant barrier to implementation is a resistance to change.

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Implementing an EMR involves significant change, and if that change was not sought by staff, significant resistance may be the response. She found that the most important factor influencing the attitude a nurse ultimately adopts towards an EMR are the change management techniques used.

Nurses emphasized the need to be involved in the decision making process from the beginning as part of project teams and usability testing. Neglecting to manage the human side of technology implementation led to serious challenges and failure for the EMR to be adopted.

As a change management strategy prior to the roll out of an EMR, McLane surveyed a sample of staff to gain an understanding of their experience with and opinions about computers and their expectations for the EMR.

Concerns about patient confidentiality and nursing workload were raised in the surveys. Survey data was used to guide staff education about expected benefits of the EMR and when those benefits would be seen, as well as patient safety features of the EMR including confidentiality protection.

Medical record

The survey data also guided the development and design of the nursing documentation feature. Assessing and recognizing the attitudes and expectations of staff prior to the implementation of the EMR allowed the planning team to create a system that met the needs of its users and resulted in a successful launch of their EMR.

Results of the study showed performance expectancy or the degree to which an individual believes an innovation will help them perform their job, and social influence or the degree to which an individual feels social pressures to use an innovation, were significant factors in EMR adoption.

Social influence was found to be the most significant factor with nurses having the strongest influence on the attitudes and perceptions of their nursing coworkers. Nurses in this report were more concerned about the impressions of other nurses than the improved productivity provided by the EMR.

This brief review of the literature highlights the importance of understanding the human side of technology implementation. Discrete barriers and facilitators to successful EMR implementation varied, but the need to address the human factors in change was clear.

I believe that this investment in people can be facilitated through the thoughtful application of change management theory. Both of these models provide steps and guidelines for engaging individuals and organizations to support both willingness and ability, thus helping to improve the likelihood the EMR would be adopted.

This dynamic model is comprised of eight stages that can be organized into three phases. Creating a climate for change The first stage is establishing a sense of urgency. The biggest mistake in attempting change is to allow complacency Kotter, This is a critical step because without a sense of urgency people will cling to the status quo and resist change.Nov 16,  · Note: If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the.

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Request for Copies of Medical Records. Medical records include but are not limited to a patient’s medical history, test results, office visit notes, discharge summary, and operative reports of treatments and medical. The same info as provided by GPs to patients during consultations,health/disease leaflets,patient support orgs,all about medicines,book GP appts online,interactive patient experience forum.

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