The electronic health record (EHR) and the legal health record (LHR) are both documents containing patient information but the goals in making the records are different. The EHR is defined as “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization” (Fahrenholz, C. G. & Russo, R., 2013b). The Office of the National Coordinator for Health Information Technology (ONC) has published a list of required items an EHR must have to satisfy the complete EHR definition. According to the ONC, the EHR must include, for both ambulatory and inpatient systems: computerized provider order entry, demographics, a problem list, a medication list, a medication allergy list, clinical decision support, transitions of care, data portability, clinical quality measures, authentication, access control and authorization, auditable events and tamper resistance, audit reports, amendments, automatic log-off, emergency access, end-user encryption, integrity, drug-drug and drug-allergy interaction checks, vital signs, body mass index and growth charts, electronic notes, drug-formulary checks, smoking status, image results, family health history, patient list creation, patient-specific education resources, electronic prescribing, clinical information reconciliation, incorporation of lab tests and values/results, immunization information, transmission to immunization registries, transmission to public health agencies-syndromic surveillance, automated measure calculation, a safety-enhanced design, a quality management system and be able to view, download and tra... ... middle of paper ... ... healthcare organization would want to use the smallest amount of information necessary to prove their case in a court of law or to an insurance company. The federal government has set standards for what must be included in the EHR but healthcare organizations must set their own standards for what they will include in their LHR. The biggest difference between the EHR and the LHR is what is being kept safe. Many of the ONC’s requirements for an EHR are not directly related to caring for patients but are related to keeping patient information safe; for example: authentication, access control and authorization, auditable events and tamper resistance, audit reports, amendments, automatic log-off, emergency access, end-user encryption, and integrity. In contrast, the information found in the LHR is meant to keep the healthcare organization safe during legal challenges.
The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Stage 1: This stage is primarily for meaningful use of an EHR in a clinical setting. The EHR technology the physician uses must meet at least 15 requirements and 5 “menu” criteria that are listed in the HITECH Act. The EHR used must be able to store patient demographic information, an e-prescribing with drug interaction alert content, and contain patient’s insurance information.
Portability can improve patient care. Patients no longer have to “tote” their cumbersome medical records around anymore. EHR’s give physicians and clinicians access to critical healthcare information in the palm of their hand, which ultimately leads to improved patient care outcomes. EHR’s also provide security to vital medical and personal healthcare information. Organizations like HIPPA defines policies, procedures and guidelines for preserving the privacy and security of discrete distinguishable health information (HHS.gov,
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an incentive, the government began issuing payments to those providers who “meaningfully use certified electronic health record (EHR) technology.” (hhs.gov) There are three stages that providers must progress through in order to receive theses financial incentives. Stage one is the initial stage and is met with the creation and implementation of the HER in the business. Stage two “increases health information exchange between providers.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) Stage three will be the continuation and expansion of the “meaningful use objectives.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) The hospital, where I work, initiated the HER mandate many years ago. In this paper, I will discuss the progression and the challenges that my hospital encountered while implementing the EHR mandate.
Electronic Health Record (EHR) is a digital collection of patient health information instead of paper chart that captures data at the point of collection, supports clinical decision-making and integrates data from multiple sources in any care delivery settings. The health record includes patient’s demographics, progress notes, past medical history, vital signs, medications, immunizations, laboratory data and radiology reports. National Alliance for the Health Information Technology defines EHR as, “ an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
The EHR is a computerized health record that will take place of the paper chart. The health care information will be available to all health care providers at anytime, anywhere. The record will contain medical history, diagnosis, medications, immunization, allergies, diagnostics and lab results; from past doctors, emergency department visits, school, pharmacies, and out patient laboratories and facilities (Department of health and human services, 2014). Health care providers will be able to access evidence-based tools to aid in decision-making. EHR will also streamline workflow, and support changes in payer requirements and consumer expectations. In 2004, “the HHS secretary, Tommy Thompson appointed David Brailer as the national health information coordinator to provide: leadership for the development and nationwide implementation of a interoperable HIT infrastructure, with the goal of establishing electronic health records...
Provides a basic level of interoperability among electronic health records (EHRs) maintained by individual physicians and organizations
Doctors, hospitals and other care providers dispute that they should have access to the medical records and other health information of any patient citing that they need this information to provide the best possible treatment for proper planning. Insurers on the other hand claim they must have personal health information in order to properly process claims and pay for the care. They also insist that this will provide protection against fraud. Government authorities make the same arguments saying that in providing taxpayer-funded coverage to its citizens, it has the right to know what it is paying for and to protect against fraud and abuse. Researchers both medical and none nonmedical have the same argument saying that they need access to these information so as to improve the quality of care, conduct studies that will make healthcare more effective and produce new products and therapies (Easthope 2005).
While the HIPAA regulations call for the medical industry to reexamine how it protects patient information, the standards put in place by HIPAA do not provide ...
The process of implementing an EHR occurs over a number of years. An electronic record of health-related information on individuals conforming to interoperability standards can be created, managed and consulted with the authorized health professionals (Wager et al., 2009). This information technology system electronically gathers and stores patient data, and supplies that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system functions as a decision support tool to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lower the medical costs. Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely to provide better preventive care than were healthcare professionals who did not.
Ragavan, V. (2012, August 27). Medical Records Pals Malaysia : 17 Posibble Reasons How Electronic Medical Records (EMR) Might Support Day-to-Day Patient Care. Retrieved from Medical Records Pals Malaysia: http://mrpalsmy.wordpress.com/category/emr/