1. Review the UMUC Family Clinic Case Study and identify two types of external organizations (e. g. , hospitals, nursing homes, rehabilitation centers, laboratories, pharmacies, etc. ) with which the UMUC Family Clinic needs to communicate and the purpose of the communication. An external organization Dr. Tom office must communicate with is a hospital. The communication will be both incoming and outgoing. Health care expert, Sprague, N. (2015), stated that with Health care reform aimed at reducing healthcare cost, there is a push to deliver more services on an ambulatory basis.
He provided the example that historically it as the norm to admit newly diagnosed diabetics to hospitals for at least several days to start insulin therapy and provide the patient the proper education about monitoring their condition. However, admission for these reasons, likely sees a denial of payment to the hospital, from the insurance company. This is so because the expectation is that this patient should be treated in doctor’s offices or clinics on an outpatient basis. The consequence is that hospitals main function is to facilitate only the sickest, leaving outpatient care to doctors’ offices and clinics.
Sprague explained the relationship between the physician and he hospital by stating that this is necessary so that in the event the patients become sick, the physician can send them to those hospitals. He elaborated on the relation as necessary so that the physician can communicate with the hospital staff to coordinate their patients’ care, visiting the hospital either before or after their workdays to gauge their patients’ progress and issue orders for their continued patient care.
Laboratories- The results of tests performed in the clinical laboratory, is crucial in helping the physician to make an appropriate diagnosis and to evaluate the effectiveness of his treatment plan. Laboratory tests of all kinds are important in that they provide information useful in the prevention, diagnosis, the treatment, and management of disease. In the laboratory a medical team of pathologists, specialists, scientists, technologists, and technicians work together to determine the presence, extent, or absence of disease and provide data needed to evaluate the effectiveness of treatment.
The communication between the UMUC Clinic and the laboratory is also a two way process. The physician orders the relevant test, the laboratory perform the study and communicates its finding in a timely manner so that he appropriate action can be taken for the patients well-being. Make a list of at least five data elements or items of information that would be shared with each external organization, and explain whether that information is going out from the UMUC Family Clinic or coming in from each of the two external organizations.
Note: More than five data elements are required to earn full points. Clinical Data Elements Patient’s complete history- This is also a two-way communication. If the physician is sending his patient to be admitted to the hospital or if the patient was admission and this is a follow up with the physician. In terms of the laboratory the information is also two ways, but more limited. Initially the physician orders the test, the lab forms the test and communicates the finding, and the patient’s history is not necessarily relevant to laboratory. Allergies- Adverse drug reactions contribute significantly to patient morbidity and mortality.
Hospitalized patients are at an extremely high risk of ADRS due to the number of diagnostic and therapeutic procedures that they undergo on a daily basis. (Radford, A. , Undre, S. , Alkhamesi, N. , & Darzi, S. , 2007). This communication is two ways, both the physician and the hospital must be aware f any allergies so that the proper precaution can be made. In terms of the laboratory, this information is not needed. Immunizations -Hibbs, B. , Moro, P. , Lewis, P. , Miller. E. , (2015), stated that medical errors because of vaccination are preventable events. They explained that these errors could have impacts; possible injury, additional cost, inconvenience, including inadequate immunological protection, and could ultimately reduce confidence in the healthcare delivery system. (Hibbs, B. , Moro, P. , Lewis, P. , Miller. E. , (2015).
This data element also requires a two-way communication channel between Dr. Tom office and the hospital, the laboratory is not involved, as this does not affect the result of any laboratory test done. • Diagnostic tests – Initial diagnosis tests, this may include results of echocardiogram, electrocardiograms, x-ray, ultra sound, CAT scan and MRI tests. These results are important in helping to diagnose and treat the patient and should be communicated to both the physician’s office and the hospital. This is not a required data that the laboratory needs. • Medications- Medication histories are important in preventing prescription errors and consequent risks to patients.
Apart from reventing prescription errors, accurate medication histories are also useful in detecting drug-related pathology or changes in clinical signs that may be the result of drug therapy. This data element is also a two-way communication between the physicians’ office and the hospital, again this element is not a requirement for the laboratory. 2. Research, list and discuss three legal, regulatory, or ethical considerations that would relate to this data exchange and explain what needs to be done to ensure compliance with each.
You must include at least one legal/regulatory consideration and at least one ethical consideration. In an article, Ozair, F. , Jamshed, N. , Sharma, A. , Aggarwal, P. (2015), lauded the benefits of EHR to increase, substantially the quality of health care and its effectiveness in reducing cost. However, they listed these as ethical possibilities: privacy and confidentially, security and data inaccuracies. In order to ensure compliance, there will be appropriate administrative, technical, and physical safeguards in place.
This will prevent the disclosure of protected health information, For example, shredding documents containing protected health information before discarding them, securing medical records ith lock and key, using or pass code, and limiting access to only those who function requires the documentation. Kreidler, M. L. (2015), added that ethical issues could result due to the different values and beliefs between the patient and practioner. He cautioned variables between race, ethnicity, and gender could affect the standards set in the clinical guidelines.
In addition, patient lifestyles may also not be reflected in the clinical guidelines (e. g. smoking, failure to exercise, overeating). Clinician must be aware treat patient with dignity and respect regardless of ethic, race, or any other financial disparities. Sittig, D. , Singh H. , (2011), addressed the issue of legality, they stated that with EHR there comes an increase responsibility and accountability for the clinicians. Using EHR there is an audit trail of all who have access to the information.
In the case where an abnormal findings for a patients is documented and reviewed by many clinicians, but this finding was never addressed, dues to an assumption that someone else have or will take care of this. The dilemma will be who is legally responsible. The range of legal issues was addressed by Gamble, M. , (2012), who wrote that with the use of an EHR system physicians might be tempted o the copy and paste feature, which can create errors in documentation. By relying on this feature to create documentation, the issue of authorship can be an issue if this particular record is investigated.
In order to ensure compliance, physicians must ensure that any abnormality is addressed and immediately and refrain from using copy and paste feature of the system. Sittig, D. , Singh H. , (2011), stated that enhanced portability and accessibility of EHR raises ethical questions regarding the ownership of these protected health information, in addition, there is the responsibility of clinicians nform patients of the potential for privacy breaches. All parties involved should be protective of the patients’ health data. revent and Kaplan, B. , (2014) advised that an important reason in protecting health data is that this is vital in maintaining trust between the health practitioner and their patients. He argues protecting health record serves the interest of both social and public order and it is important and vital in providing quality care of the patients. There is currently no law in the State of Maryland that addresses the issues of ownership; however, Dr. Tom must ensure that his patients have access to their medical records.