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Electronic health record introduction
Introduction to electronic medical record essay
Electronic medical records research paper
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It was just yesterday when Electronic health records was just introduced in healthcare industry. People were not ready to accept it due to higher cost and consumption of time associated in training people and adopting new technology. Despite of all this criticism, use of Internet and Electronic Health records are now gaining its popularity among health care professionals, as it is the most effective way to communicate with patient and colleagues. More and more hospitals and clinics are getting rid of paper base filling system and investing in cloud base storage.
According to HIMSS The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. It includes information from patient demographics, medications, to the laboratory reports. Introduction of Electronic Medical Records in healthcare organizations was to improve the quality care and to lessen the cost by standardizing the means of communication and reducing the errors. However, it raises the “eyebrows” of many when it comes to patient confidentiality and privacy among healthcare organization.
The Problem is
1. Transfer of Information- The problem is remote access of the health records and pooling of large number of data for various purposes like research program and lab work, may lead to an error and confusion.
2. Lack of information centralization- Many patients keep their own records of blood sugars, weight and blood pressure by using various Internet tools. However, healthcare providers cannot access these records because they cannot streamline those records with EHR.
3. Security theft - Internet tools like Google health and Microsoft Vault provides conveni...
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...idence of users by agreeing to the policy that the data submitted to their cloud platform will be kept confidential. (Ryan, 2011)
The cloud computing is still under development but if it can manage to maintain information privacy and confidentiality than it will become revolutionary in healthcare field. And we never know, in future science and technology might introduce more advanced level of apps and service with enhanced level of privacy and security measures.
Patient personalized health cards are also long underling technology that might provide patient a freedom of owning his/her PHI. Transferring data from one hospital to another wouldn’t be a challenge with this password protected health cards. Privacy wouldn’t be much of an issue as all the information is stored in the chip of the card that can be retrieve by a healthcare provider or by patient when needed.
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
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,
HIPPA (Health Insurance Portability and Accountability Act) was put in place by the Federal Government for several reasons; better portability of health insurance for employees, to prevent fraud and abuse within the healthcare delivery system, and simplification of administrative functions associated with healthcare delivery (McGonigle & Mastrian, 2012). Due to sensitive healthcare information being shared federal regulations were also put into place, resulting in the “Privacy Rule” and “Security Rule”. The Privacy Rule limits the use and disclosure of patient information. The Security Rule protects the patients’ healthcare information from improper use or disclosure, to maintain information integrity, and ensure its availability (McGonigle & Mastrian, 2012). Both regulations apply to protected health information (PHI) which is any form of health information that can be used to identify an individual patient. Practitioners who refer to HIPPA are not referring to the act itself but the “Privacy Rule” and “Security Rule” (McGonigle & Mastrian, 2012). It is extremely important to understand these concepts as a student in the clinical setting and how each hospital enforces these concepts. Before starting at any clinical site there is an extensive orientation about HIPPA regarding what is appropriate and not appropriate when it comes to patient information and the repercussions of violating HIPPA. In this paper I will discuss Akron General’s rules and policies regarding their EHR, PHI, EPHI, and social media.
In the modern era, the use of computer technology is very important. Back in the day people only used handwriting on the pieces of paper to save all documents, either in general documents or medical records. Now this medical field is using a computer to kept all medical records or other personnel info. Patient's records may be maintained on databases, so that quick searches can be made. But, even if the computer is very important, the facility must remain always in control all the information they store in a computer. This is because to avoid individuals who do not have a right to the patient's information.
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.
In order to integrate health information systems and ensure security of a patients stored information, I think it would be wise to incorporate more than one method in order to provide optimum security. Devices such as CD’s and USB drives can easily get lost, are unable to provide one hundred percent secure security and it slows down the process to provide a patient with care. Online storage clouds integrated with other forms of protection, like the patient card and pin number, can allow us to use online storage and better fight identities being stolen. The future of healthcare is technology centered and healthcare needs to be ready to embrace it. Health information systems have much to offer if they are developed properly. Health information systems have the potential to take the quality of patient care to a whole other level, a level that will increase efficacy an create a vessel for information to transfer. Making sure that information is securely stored and that the individual who is accessing that file from a storage database will not jeopardize a patient’s
Allowing all these different information technology system to communicate and exchange data we improve diagnostics and care coordination. Not only that but the financial incentives too, the healthcare center will benefit in administration and financially. Using Electronic Health Record files will be in clinical orders and patients will also have their own
From the patient’s perspective, better diagnosis of pre-existing diseases, notable fall in the errors found within the personal record of patient, proficient and quicker responses from the care providers are the positive dimensions. Furthermore, EHR system attempts to curb some issues such as lack of time during the patient’s visit and health professionals not realizing the right guidelines for the right patient at the right moment. Patient safety has also been central among the other outcomes which is described as avoiding injuries to patient from the care delivered to them. Implementation of HER under the initiation of Health information technology has stirred the practitioners by the same token. The undertaking of quick data transfer from one department to another is genuinely commendable.
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
The information record in an electronic format in the context of health has been studied and analyzed because is very important for the health care of people. The potential of clinical information safe and available in the moment of the clinical decisions are taken, in the individual context or with populations, is undeniable (10,12,15). The record format known as Electronic Medical Record (EMR) is a digital version of a paper chart in a clinician’s office. It is a repository of clinical and administrative information where are stored during all the patient`s life (14). However, the EMR involves frequently just one health facility and, sometimes, a single software for information management (19). For many health facilities at different levels of care can exchange the clinical history contained in EMR, a new concept arise: the Electronic Health Record (EHR). It is a longitudinal data repository formed from multiple events in health facilities and over time. The challenge is to standardize the format and the meaning of health data and make them available in an integrated manner throughout the life (1).
Nursing has come a long way from paper recording in vital signs, medication administrations and notes writing. The development of the modern technology and internet based devices had transferred the way of healthcare system. Modern nursing has become electronically done whether using mobile devices or a lap top attached to the nursing cart while delivering care. According to Charles, Gabriel and Searcy (2015), the modern technology developed Electronic Health Records (EHR) system which have changed patient center care process along with changing in patient education system. EHR as new developed technology in the medical professions, dealing the update system uses, modifying in patient education and nursing practices.
Electronic health records came into practice to improve patient care and efficacy. It provides a full medical record history of patient’s demographics, insurance information, past surgical, medical and family history and much more. The goal of EHR is to improve in quality management for patients, increase efficiency, improve medical practices, and enhance communication amongst providers, patients and health plans. EHR tested by ONC-ATB works with public and private sectors to develop and improve healthcare in America. This is a vital goal of the development and implementation of software systems in medical facilities.
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).
“At its most basic, cloud computing is moving applications accessible from our internal network onto an internet (cloud)-accessible space. We're essentially renting virtual machines in someone else's data center, with the capabilities for immediate scale-out, failover, and data synchronization. In the past, having an Internet-accessible application meant we were building a website with a hosted database. Cloud computing changes that paradigm—our application could be a website, or it could be a client installed on a local PC accessing a common data store from anywhere in the world. The data store could be internal to our network or itself hosted in the cloud.” (Duchene, 2010)
Google uses data encryption as a method of ensuring that data stored in its cloud is secured and confidential (Bradley, 2010). GovCloud is a special cloud established by Google for storing government related information and data (Bradley, 2010). Due to the sensitivity of the information stored in GovCloud, Google encrypts the data in such a way that the data is not availab...