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A Problem of Display Codes Case Study

Student’s Name

Institutional Affiliation

Course Code and Name

Instructor’s Name

September 14, 2021

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Applicable Healthcare Considerations

Electronic medical record encompasses information about the health history of the patient

such as immunizations, allergies, medicines, diagnoses, as well as treatment plans. The

utilization of electronic medical records in healthcare helps in making various recommendations

about the care of the patient. It is described in other terms as an electronic health record

(Cucciniello et al., 2015). Despite the efficacy of the technology in the management of health

records, it presents a myriad of drawbacks in the implementation and usage. One such issue

revolves around designing the most appropriate screen for displaying codes (Brown, Patrick &

Pasupathy, 2018). The main problem outlined in the case study is figuring out the standard codes

that are supposed to be utilized on the display user screens when it comes to the implementation

of the electronic medical record project at the largescale medical center. The decision must

encompass content for standards, descriptions, and in particular abbreviations for medicine,

pharmacy, purchasing units, and nursing (Cucciniello et al., 2015). Presently, the system is

providing different standard abbreviations for terms that are utilized on daily basis. Even though

it is suitable to utilize most of the variations of these abbreviations, one of the abbreviations is

supposed to be decided upon as a ‘standard’ in their practice to make sure that the system will

operate effectively. The problem can be ascribed to the integration of the systems which causes

sharing of information across multiple disciplines.

Information System Consideration

A sustainable solution is having experts that operate in these departments come up with a

standard vocabulary as well as mapping systems that make sure that each of the departments

locally and globally are using similar abbreviations and terminology in the same way as the

electronic medical record system (Cucciniello et al., 2015). Currently, there are different options
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for all the vocabulary words that the system is not up to the right standard and is running into

database problems. The best approach to this issue is to redesign the display screen system with

an electronic medical record code or system (Cucciniello et al., 2015). Because the existing

system is old-fashioned and requires transformation, integration, as well as updating to the

contemporary standards that are used nationally and internationally (Brown, Patrick &

Pasupathy, 2018)

.Stakeholders Engaged in the Outcome

The stakeholders that are engaged in the outcome are health informatics. Health care

informatics experts have to be well informed concerning medical billing and coding, medical

database operation, HITECH, as well as other federal privacy and health laws (Nelson, &

Staggers, 2018) They help in establishing and enhancing databases and improving databases.

From the case study, it is apparent that the help needed by Michael would not be adequate.

Michael needed a team of people with the right skills to handle the enormous task (Cucciniello et

al., 2015). From the case study, the nurses, clinicians, and in particular physicians are required to

be engaged in the process either by being involved to participate or by being consulted. This

venture of establishing standard displays data in the electronic medical records is enlarged, is

laborious, and costly (Sochi, 2016). For that reason, personnel and time are needed to ensure

everything is done in the right way. Therefore, the individuals mentioned form an important part

of the stakeholders.

The Possible Course of Available Actions

One of the possible causes of action is narrowing the issue much more specifically.

Patrick is entirely right on what is the root of the problem. Despite calling for the standardization

of terms concerning the different national and international standards, the bottom line of the
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issue is not clear. The best course of action is to explain the ways in which specific areas such as

tracking, identification, monitoring, as well as enhancing can be promoted (Sochi, 2016).

Tracking of the patient can be enhanced with a more logical and comprehensive information

entry, for instance, the issue may not be abbreviation but instead the codes themselves. Through

the fixation of the poor abbreviation standardization, Patrick is missing the resolution of ensuring

everything is standardized (Brown, Patrick & Pasupathy, 2018). For that reason, proper training

is also needed to completely get rid of this problem. Therefore, the analysis of this case study

presents invaluable insights into the flaws of the electronic medical record systems.

Predicted Effects of Each Course of Action

One of the predicted outcomes is the improvement in the focus of patient safety via

clinical decision support as well as the reduction of medical errors. Proper coding allows a more

reliable and safer prescribing. It also helps in promoting complete and legible documentation and

precise, streamlined billing and coding. Another outcome will be an improvement in the security

and privacy of the patient data as well as helping the healthcare provider enhance work-life

balance and productivity. Medical coding helps in capturing important information about the

treatments, diagnoses, equipment, and medications and translate them into alphanumeric codes

(Brown, Patrick & Pasupathy, 2018). The information stems from a plethora of sources such as

electronic records, transcriptions, and medical notes, lab results including blood work, radiologic

evaluations, as well as urinalysis and pathology. Medical coding experts tend to transfer the

codes from their sources to the patient records and medical billing systems. Coding is a critical

phase that is needed in the submission of medical claims with insurers, and bills for patients and

insurers (Brown, Patrick & Pasupathy, 2018). Therefore, proper coding of the electronic medical

records will influence positive outcomes for the patients.

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Additional Questions Identified in the Case Study

One of the questions that lingered in my mind when I scanned through the case study is

what I would have done if I happened to be in such a situation. I recall a healthcare practitioner

who had extensively used electronic medical records for 10 years. It happened that she

encountered a challenge of the noted in the system whereby they became a bit different from

each other (Nelson & Staggers, 2018). In order to resolve the problem, the hospital created a

committee that was to work on the project and help in the standardization of the notes, from

various regions of the hospital (Nelson & Staggers, 2019). If I happened to be in a similar

scenario, I would establish a committee that comprises different leaders within the hospital and

collaboratively work on the standards. I would listen to the opinion of every person to streamline

the electronic medical records as much as possible for every individual (Nelson & Staggers,

2018).

My Opinion

From the above scenario, I am of the opinion that electronic medical records are pivotal

to the healthcare sector because they help in reducing patient delays and enhancing patient

outcomes. However, they have various drawbacks which require a constant inspection to

pinpoint and rectify them appropriately. The USF Health states that the EMR improves patient

care (USF Health, 2016). A good example is when the clinical synopsis that is available for more

than half of all the visits is relayed to the patient within a period of three business days. The

summary is composed of the information regarding the care being provided in the course of the

visit, the prescribed medications, related medical advice, as well as the upcoming or follow-up

appointments (USF Health, 2016).

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References

Brown, G. D., Patrick, T. B., & Pasupathy, K. S. (2018). Health informatics: a systems

perspective. Health Administration Press

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Cucciniello, M., Lapsley, I., Nasi, G., & Pagliari, C. (2015). Understanding key factors affecting

electronic medical record implementation: a sociotechnical approach. BMC health

services research, 15(1), 1-19.

Nelson, R., & Staggers, N. (2018). Health informatics. An interprofessional approach

Sochi. (2016). Why Are Medical Billing and Coding So Important? Southern California Health

Institute. Retrieved from https://www.sochi.edu/blog/why-medical-billing-coding-is-

important.html

USF Health. (November 2020). What is EMR? USF Health. Retrieved from

https://www.usfhealthonline.com/resources/key-concepts/what-are-electronic-medical-

records-emr/