In the Midwest, a small community hospital has for years been using homegrown information system. However, there was the overtime addition of modules whereby there were selected interfaces and commercial operations by a limited number of departments to integrate these modules into the hospital information system overall functionality. Most of the documentation was, however, online except for physicians. However, one of the concerns about this online documentation was approximately 20% of online documentation is conducted by free text and is ineffectively searchable.
The other concern is that the screens which were inclusive of default values and drop-down were generated by the use of selected terms by the in- house development team and the clinical staff consultation. This, therefore, meant that there was no specific standard language or data dictionary used in the hospital.
The final concern is that the hospital was able to purchase two outpatient clinics, namely the mental health and obstetrics as well as several local doctor practices. This action led to the conversion of doctors’ offices and clinics to hospital administrative systems.
However, several recommendations can be able to improve efficiency using the existing system. Before deciding on the implementation of a successful improvement program, the policymakers and hospital administrators should assess potential gains that could be gained through the reduction of inefficiencies. The proper organization of online documents is another essential step that would ensure effective searchability (Adams & Markowitz, 2018) The hospital can ensure this through the maintenance of a central database for the location of similar-minded hospital documents. The hospital should also provide the site of a specific standard language since it is vital in nursing care documentation and effective communication among nurses and other health caregivers that would ensure efficiency. The hospital should also consider calling for the creation of new doctors’ offices to avoid inconveniences when health caregivers want to perform specific office duties.
The Nursing Intervention Classification (NIC) overview
The NIC describes treatments performed by nurses in various settings, populations and specialities. It was developed and maintained by the Low university college of nursing (Butcher et al., 2018). The NIC is essential for care communication across settings, clinical documentation, and productivity measurement, data integration across systems, competency evaluation and in research effectiveness. The NIC is irregularly updated with the last update dating back to 2008 (Butcher et al., 2018). The available cross maps in NIC include nursing interventions such as mobility therapy and diet compliance and nursing activities.
Multidisciplinary Standard Language (ABC codes)
Alternative billing concepts (ABC) codes were developed initially to process certain claims that aim at addressing complementary, conventional as well as alternative health care services that are not routinely included medical systems of billing traditionally (Kliethermes, 2017). They were initially produced and maintained by ABC coding solutions. The ABC odes offer detailed health care services description to ascertain appropriate and effective reimbursement. They play a significant role in filling missing gaps situated in older systems of medical coding, which then makes the new system of billing cost-effective and more reliable (Kliethermes, 2017). The available cross maps in ABC Coding include management practice, insurance claims, administrative activities and medical record keeping. ABC codes are however annually updated.
- What are the potential benefits of data transformation from the existing system?
- How effective is the electronic medical record system in the functioning of the hospital?
- Is online documentation effectively searchable?
- What are the most appropriate ways of managing system downtime in the hospital?
- What are some of the examples of hospital downtime procedures?
References
Adams, E. K., & Markowitz, S. (2018). Improving efficiency in the health-care system: Removing anticompetitive barriers for advanced practise registered nurses and physician assistants. Policy Proposal, 8, 9-13.
Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. M. (2018). Nursing Interventions Classification (NIC)-E-Book. Elsevier Health Sciences.
Kliethermes, M. A. (2017). Understanding health care billing basics. Pharmacy Today, 23(7), 57-68.