Hampe Holly M, Keeling Terri, Fontana Michelle, Balcik Debbie
Health Service Administration, Robert Morris University, Moon, Pennsylvania (Drs Hampe and Keeling); and Trauma and Burn Program, UPMC Mercy, Pittsburgh, Pennsylvania (Mss Fontana and Balcik).
Crit Care Nurs Q. 2017 Jan/Mar;40(1):8-15. doi: 10.1097/CNQ.0000000000000135.
Improving patient care through enhanced electronic communication among health care providers is aimed at reducing the number of medication and medical errors. The American Reinvestment and Recovery Act (ARRA) was signed into law in 2009, supporting the federal government's commitment to the improvement of health care quality, safety, and efficiency through requirements to implement an electronic health record by October 2015 or hospitals and eligible providers potentially realizing penalties or reduced reimbursement rates. In addition to ARRA, Congress presented another initiative to further advance the delivery of high-quality health care, the Health Information Technology for Economic and Clinical Health Act (HITECH), leading to the authorization of $27 billion to encourage health care providers to achieve meaningful use of the electronic health record. However, the conversion of the paper medical records to an electronic version has been challenging, particularly in specialty departments. The burn unit of a tertiary hospital located in the Pittsburgh area experienced such challenges. A project plan, developed in 2009 prior to the electronic medical record going live, involved a multidisciplinary team, consisting of providers, nurses, and information system builders who came together to determine how to capture the totality of the burn unit documentation. The goal of the project was to develop an electronic documentation tool and provide a system to accurately and efficiently evaluate documentation compliance with the staff. The Lund Browder documentation tool, used with the paper medical record, was the selected tool for the electronic conversion. This tool has been regarded by most health care organizations as being the most accurate in measuring the extent and degree of the burn. With the paper documentation tool, the staff was, on average, 74% compliant with the Lund Browder tool. The electronic version and availability of the tool increased compliance to 100% in the fourth quarter of 2015.
通过加强医疗服务提供者之间的电子通信来改善患者护理，旨在减少用药和医疗差错的数量。《美国复苏与再投资法案》（ARRA）于2009年签署成为法律，通过要求在2015年10月前实施电子健康记录，支持联邦政府致力于提高医疗质量、安全性和效率，否则医院和符合条件的提供者可能会面临处罚或报销率降低。除了ARRA，国会还提出了另一项倡议，以进一步推进高质量医疗服务的提供，即《经济和临床健康医疗信息技术法案》（HITECH），该法案授权270亿美元，以鼓励医疗服务提供者有效使用电子健康记录。然而，将纸质病历转换为电子版本一直具有挑战性，尤其是在专科部门。位于匹兹堡地区的一家三级医院的烧伤科就经历了这样的挑战。在电子病历上线之前的2009年制定的一个项目计划，涉及一个多学科团队，由提供者、护士和信息系统建设者组成，他们共同确定如何获取烧伤科文档的全部内容。该项目的目标是开发一种电子文档工具，并提供一个系统来准确、高效地评估工作人员的文档合规情况。与纸质病历一起使用的伦德·布劳德文档工具，被选为电子转换的工具。大多数医疗保健组织认为该工具在测量烧伤的范围和程度方面是最准确的。使用纸质文档工具时，工作人员平均有74%符合伦德·布劳德工具的要求。该工具的电子版本和可用性在2015年第四季度将合规率提高到了100%。
