Healthcare Data Capture

Study Notes

Capturing or inputting data electronically where and when a transaction occurs, and entering gathered data and information about patients where it originates
The concept of computer terminal by the bedside was introduced in the mid-1980s
Point of care systems are widely used now, and their potential has been fully utilized
Bringinging the computer access closer to the patient (i.e., locating it at the point of care) is a valid premise and clinicians favor the bedside terminal as a means to reduce clerical workload and improve access to clinical data

Must permit nurses at the patient's bedside to interact with the main patient database and the main care planning system or hospital information system
Must have the capacity to interact with existing hospital information system
Must be small and compact, rugged and durable, easy and uncomplicated to use, and have high-resolution screens with graphics capability
Must allow for a variety of means of data entry (e.g., bar code reader, physiological probe, digital camera, natural language, or keyboard)
Must have a volume control to mute any keyboard sounds and provide two-way radio transmission of data with an acceptable level of security and confidentiality for patient information

Standard stationary terminal
Specially designed for the purpose of source data capture, including small footprint terminal, fixed at the bedside, and having special function keys for data input
Hybrid solution that attaches to the wall in the patient's room when not in use but is portable and interactive within the patient's room
Handheld portable terminal, not restricted to a particular care field, with point of care or source data capture devices

Nurses document their work in Point of Care Technology (POCT) for communication within the health care team, to provide information for other professionals, and for individuals and groups involved with accreditation, credentialing, legal, regulatory, and legislative activities
The demand for POCT is stimulated by factors such as the increasing prevalence of infectious diseases, the rising incidences of lifestyle diseases, and technological advancements
Source data capture can be more greatly exploited by nurses if assessment guidelines and interview instruments were developed to be downloaded to the point of care device
Data input of responses in an interactive manner at the patient's bedside will enhance the use of source data capture

Standards are critical in the development and implementation of electronic health records (EHRs)
Nurses continually use mental processes to organize information systematically by grouping data according to common features
The challenge is that nurses do not have a common system or language to communicate precisely, even with each other
A common nursing language has been developed, but it is rarely used
Patient discharge abstracts prepared by medical records departments in hospital contain no nursing care delivery information
Patient discharge summaries need to include nursing workload data that recognize the personnel providing the care in addition to the substance of that care

Decision Support System (DSS) are a computer-based form of decision tool, integrating information with the characteristics of individual patients, to provide advice to clinicians
Clinical Decision Support (CDS) has been shown to lead to significant quality and safety improvements in patient care and improve workflow among clinicians
CDSS is a computer software application that matches patient characteristics with a knowledge base to generate specific recommendations
Decision support can take many forms and is often integrated subtly into many aspects of an EHR
Six major uses of decision support system have been identified:
- Alerting: notify clinicians of an immediate problem that calls for a prompt action or decision
- Interpretation: interpret particular data such as electrocardiogram or blood gases and transform it into a conceptual understanding or interpretation