D220 Task 1 Exploring EHRS in Home Health Care Settings
A. Identify a healthcare setting and an electronic health record system (EHRS) that could be used in this setting
What is a suitable healthcare setting and EHRS system for home healthcare?
Home healthcare is a vital and often under-discussed area where Electronic Health Record Systems (EHRS) are becoming increasingly important. Data from 2017 indicate that nearly 78% of home healthcare agencies had adopted some form of EHRS. One widely used system designed specifically for home health is Homecare Homebase (HCHB).
HCHB functions much like other EHRS platforms, emphasizing continuity of care by enabling real-time documentation in patients’ homes. It also improves access to clinical records for field clinicians. This system aims to enhance patient safety, streamline care processes, boost operational efficiency, and support management of chronic illnesses (Hobensack et al., 2021).
A notable feature of HCHB is its ability to capture Outcome and Assessment Information Set (OASIS) data. This capability helps recommend the number of patient visits based on the acuity level, supporting personalized, data-driven care plans.
However, several challenges exist in this setting, including unreliable internet connectivity in rural areas, which can delay data uploads or downloads and cause documentation gaps. Incomplete referral information may also lead to missing critical details such as medication lists or allergy histories.
| Challenge | Recommended Solution |
|---|---|
| Unstable internet in rural areas | Maintain paper-based charts as a backup |
| Missing referral documentation | Collect primary source data like medication bottles |
| Incomplete medical histories | Request medical records from referring providers |
Accurate data entry in the system enables medication interaction checks and supports precise diagnoses. This ultimately leads to better patient outcomes, improved clinical assessments, and more tailored patient education.
B. Identify one health information system and one technology to use in the healthcare setting identified in part A
Which health information system and technology can be applied in home health care?
In home healthcare, the Epic system serves as a crucial health information platform. It allows clinical team leaders to securely import electronic documents into patient charts using mobile tablets. This functionality ensures clinicians have up-to-date and accurate patient data directly from primary sources.
Additionally, the WorldView application is a vital technology used in this environment. It enables clinicians to upload wound photos, scan signed documents such as service agreements or HIPAA forms, and integrate these into patients’ electronic records. This facilitates faster documentation and enhances communication within the care team.
1. How does the health information system support decision-making in patient care?
Epic supports clinical decision-making by providing a comprehensive, real-time overview of patients’ medical histories, lab results, and care plans. This centralized access helps clinicians evaluate referral reasons, detect clinical trends, and make evidence-based decisions. It also facilitates interdisciplinary data sharing, improving coordination among healthcare providers.
| Feature | Contribution to Decision-Making |
|---|---|
| Patient history access | Identifies underlying conditions and patient risks |
| Real-time updates | Reduces clinical errors and avoids redundant tests |
| Interdisciplinary access | Promotes collaboration among healthcare providers |
| Integrated alerts | Sends reminders for follow-up care and medication safety |
2. How does the technology support decision-making in patient care?
WorldView enhances clinical decision-making through visual documentation. By uploading wound images, clinicians can monitor patient progress and compare current images with previous ones to detect subtle changes such as infections or tissue deterioration, which might not be evident in written notes. Remote specialists can review these images and provide timely recommendations, improving the accuracy and speed of care delivery.
3. Why is evaluating data from health information systems important?
Evaluating the quality, consistency, reliability, and security of data from health information systems is critical for ensuring patient safety and high-quality care. Reliable data helps clinicians make accurate decisions, while regular audits maintain data integrity and regulatory compliance. Strong security measures protect sensitive patient information from unauthorized access.
For example, discrepancies in medication lists or outdated records may cause medication errors or misdiagnoses. Data validation and encryption protocols are essential to safeguarding data accuracy and confidentiality.
C. Describe how relevant laws and policies guide the use of health information systems and safeguard healthcare information
1. What is the nurse’s ethical responsibility regarding protected healthcare information according to the AHIMA Code of Ethics?
The American Health Information Management Association (AHIMA) Code of Ethics requires healthcare professionals to ensure that data accessed through healthcare technology are not used beyond the scope of their job responsibilities (AHIMA, 2019). Nurses have an ethical duty to protect Protected Health Information (PHI) by maintaining confidentiality.
For instance, a nurse who becomes aware of patient data outside the workplace must not share or discuss this information. Upholding confidentiality fosters patient trust and preserves professional integrity.
2. What is the nurse’s legal responsibility regarding protected healthcare information under HIPAA?
Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, nurses are legally obligated to protect PHI and prevent unauthorized disclosures, whether intentional or accidental (CDC, 2024). Examples of violations include leaving patient charts open on shared devices or discussing patient information in public places.
Nurses must ensure that patient information is accessed only by authorized individuals and used strictly for treatment, payment, or healthcare operations. Failure to comply can result in disciplinary measures, financial penalties, or loss of licensure.
References
AHIMA. (2019, April 29). Code of ethics. AHIMA Body of Knowledge. https://bok.ahima.org/topics/industry-resources/code-of-ethics/
Centers for Disease Control and Prevention. (2024, September 10). Health Insurance Portability and Accountability Act of 1996 (HIPAA). https://www.cdc.gov/phlp/php/resources/health-insurance-portability-and-accountabilityact-of-1996-hipaa.html
Hobensack, M., Ojo, M., Bowles, K., McDonald, M., Song, J., & Topaz, M. (2021). Home healthcare clinicians’ perspectives on electronic health records: A qualitative study. Studies in Health Technology and Informatics. https://doi.org/10.3233/shti210763