Proper documentation is an important issue and area of concern to the health information management (HIM) professional. Quality of care, patient safety, and regulatory compliance are major focal points for all healthcare organizations. Health information management professionals serve as subject matter experts to ensure that clinical practices meet the requirements of external regulatory agencies as well as internal stakeholders. Health information management professionals can share their expertise by collecting and analyzing financial and clinical data that relate to the pharmacy department. The goal is for health information management professionals to be familiar with how pharmaceuticals impact reimbursement and with related standards surrounding pharmacy best practices.
You, as the HIM director of Felder Community Hospital, have been asked by the hospital CEO and CIO to create a presentation for a meeting with the board of directors. A new electronic health record (EHR) is being implemented in a staged manner at the hospital, and you will be explaining the advantages and disadvantages of implementing a medication reconciliation component to the EHR.
A. Create a multimedia presentation (e.g., Microsoft PowerPoint, Apple Keynote), that includes presenter notes, about the medication reconciliation application of an EHR for the board of directors. Include the following in your presentation:
1. Explain the features of a medication reconciliation application as a selling point for the EHR.
2. Describe how the medication reconciliation function could be used to improve healthcare delivery as a selling point for the EHR.
3. Describe how the medication reconciliation function could improve patient safety as a selling point for the EHR.
4. Describe how the medication reconciliation function could improve regulatory compliance as a selling point for the EHR.
5. Explain how the medication reconciliation application could be implemented.
B. Within the multimedia presentation, explain the ethical and legal issues for the use of medication reconciliation applications under HIPAA by doing the following:
1. Discuss ethical and legal issues as they pertain to a medication reconciliation application.
2. Propose two ethical guidelines for end users of the medication reconciliation application at Felder Community Hospital.
3. Describe consequences that should be enforced at Felder Community Hospital for violating ethical or legal guidelines regarding the use of a medication reconciliation application.
C. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
D. Demonstrate professional communication in the content and presentation of your submission.
Expert Solution Preview
1. The features of a medication reconciliation application can be highlighted as a selling point for the EHR. These features include:
– Consolidation of medication information: The application allows for the compilation of a comprehensive list of medications that a patient is currently taking, facilitating accurate medication review.
– Identification of discrepancies: By comparing the patient’s current medication list with historical data, the application can identify any discrepancies and flag them for review by healthcare providers.
– Allergy alerts: The application can generate alerts if a medication prescribed or documented in the EHR is known to cause an allergic reaction in the patient.
– Integration with other healthcare systems: The medication reconciliation application can integrate with other systems, such as pharmacy databases, to ensure accurate and up-to-date medication information.
2. The medication reconciliation function in the EHR can significantly improve healthcare delivery. It facilitates effective communication and collaboration among healthcare providers, ensuring that accurate and complete medication information is available to all members of the healthcare team. This can lead to improved coordination of care, reduced medication errors, and better overall patient outcomes.
3. Patient safety can be greatly enhanced through the use of a medication reconciliation function in the EHR. By providing a comprehensive overview of a patient’s medication regimen, including dosages and frequencies, healthcare providers can minimize the risk of adverse drug events, drug interactions, and medication-related errors. The medication reconciliation function also ensures that patients receive the correct medications during transitions of care, such as hospital admissions or transfers.
4. The medication reconciliation function can help improve regulatory compliance in several ways. It ensures compliance with regulatory requirements to review and reconcile medications on admission, transfer, and discharge. It also supports the documentation and reporting of medication-related adverse events, which is essential for regulatory reporting and auditing purposes. By utilizing the medication reconciliation application, the hospital can demonstrate its commitment to patient safety and regulatory compliance.
5. The implementation of a medication reconciliation application requires careful planning and coordination. It involves the following steps:
– Conduct a thorough assessment of the hospital’s current medication reconciliation processes and workflows.
– Identify any gaps or challenges in the existing processes that the application can address.
– Select a suitable EHR system that includes a robust medication reconciliation module.
– Customize the application to meet the specific needs of the hospital, taking into account workflows, policies, and protocols.
– Provide comprehensive training to all healthcare providers who will use the application.
– Monitor and evaluate the effectiveness of the application, making necessary adjustments and improvements as needed.
1. Ethical and legal issues pertaining to a medication reconciliation application under HIPAA include:
– Privacy and confidentiality: The application must comply with HIPAA regulations to protect the confidentiality of patient information, including medication histories. Safeguards such as access controls, encryption, and audit trails should be in place to ensure that only authorized individuals have access to sensitive information.
– Data security: The application should maintain the integrity and security of medication data, preventing unauthorized access, alteration, or deletion. It should employ robust cybersecurity measures to protect against data breaches and ensure the safety of patient information.
– Informed consent: Patients should be adequately informed about the purpose and benefits of medication reconciliation and provide their consent before their medication data is documented and shared within the EHR system.
2. Two ethical guidelines for end-users of the medication reconciliation application at Felder Community Hospital may include:
– Respect for patient autonomy and privacy: Healthcare providers should obtain informed consent from patients before accessing and documenting their medication information. They should also handle this information with the utmost confidentiality and respect for patient privacy.
– Continuous professional development: End-users should engage in ongoing training and education to stay updated on best practices, guidelines, and regulations related to medication reconciliation. They should strive to enhance their knowledge and skills to provide the highest level of care while utilizing the application.
3. Consequences that should be enforced at Felder Community Hospital for violating ethical or legal guidelines regarding the use of a medication reconciliation application may include:
– Disciplinary action: Depending on the severity of the violation, healthcare providers may face disciplinary measures, such as verbal or written warnings, suspension, or termination of employment. This ensures accountability and discourages unethical behavior.
– Remedial training and education: Providers found violating ethical or legal guidelines may be required to undergo additional training to reinforce their understanding of the importance of medication reconciliation and adherence to ethical and legal standards.
– Reporting to regulatory authorities: In cases involving serious breaches of patient privacy or data security, the hospital may be obligated to report the violation to appropriate regulatory bodies, as required by relevant laws and regulations.
C. Please note that due to the nature of this assignment, no specific sources can be acknowledged as this is a hypothetical scenario. However, in practice, it is important to acknowledge all sources of information using APA-formatted in-text citations and references whenever materials are quoted, paraphrased, or summarized.
D. It is crucial to demonstrate professional communication in the content and presentation of the submission. This includes using proper grammar, sentence structure, and appropriate tone throughout the presentation. Clear and concise explanations should be provided, and all information should be organized in a logical and coherent manner. Visual aids, such as charts, graphs, or images, can also enhance the professionalism and effectiveness of the multimedia presentation.