Electronic Health Record Paper
Introduction
According to the Centers for Medicare & Medicaid Services (CMS), “an EHR is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports”. (www.cms.gov, 2012). EHRs will replace paper health care records, in aid to help health caregivers provide quality patient care. It is supposed to improve quality care, reduce cost, and help resolve medication errors to help achieve best outcomes for the patient overall health care. In this paper I will discuss about the national electronic health record (EHR) mandate. I will then describe the current plan and status of my health care facility of employment in implementing this mandate. I will also analyze the plan, progress, and challenges to patient confidentiality and patient self-determination.
National EHR Mandate
The idea of mandating EHR began in 2004 when President Bush introduced his plan to have americans health records digital by 2014 to ensure safe medical practices. Having EHR would promote less medical errors, more collaboration amongst health care professionals, and reduce costs in providing quality care. It was later decided under the Obama administration in 2009 to continue with President Bush goals of EHRs and then link quality of care and payment to improve medical care and control cost of ...
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...s to dealing with EHRs. “Because practitioners, including nurses, cannot completely control access to computerized databases, concern arises that patients may withhold important health information or refrain from seeking care due to fear that their records will not remain private”. (Burkhart & Nathaniel, 2008, p. 285). Patients have the right to know who has access to their medical information and how it is being used. “It suggests that while health systems hold confidential information about patients, it is not the system’s right to use this information as it chooses. Rather, the system needs to secure patients’ consent to transfer records or data to a third party, even it is another medical caretaker”. (Elwyn & Miron-Shatz, 2011). Therefore patients should have the ability to control what is going in and out of their health records and grant access to it.
As the evolution of healthcare from paper documentation to electronic documentation and ordering, the security of patient information is becoming more difficult to maintain. Electronic healthcare records (EHR), telenursing, Computer Physician Order Entry (CPOE) are a major part of the future of medicine. Social media also plays a role in the security of patient formation. Compromising data in the information age is as easy as pressing a send button. New technology presents new challenges to maintaining patient privacy. The topic for this annotated bibliography is the Health Insurance Portability and Accountability Act (HIPAA). Nursing informatics role is imperative to assist in the creation and maintenance of the ease of the programs and maintain regulations compliant to HIPAA. As a nurse, most documentation and order entry is done electronically and is important to understand the core concepts of HIPAA regarding electronic healthcare records. Using keywords HIPAA and informatics, the author chose these resources from scholarly journals, peer reviewed articles, and print based articles and text books. These sources provide how and when to share patient information, guidelines and regulation d of HIPAA, and the implementation in relation to electronic future of nursing.
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.
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
The U. S government passed the American Recovery Act in 2009 that established incentives and penalties to promote EHR use. From this legislation the Meaningful Use Program for EHR’s s was created. Through The Meaningful Use Program the U.S. government is able to support the adoption and use of EHR technology to enhance and revolutionize health care. The goal of the program is to increase EHR adoption, improve quality, safety, reduce disparities, and improve public health (hmsa , 2012).
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.
The federal government has taken deliberate steps to ensure that EHR systems are strong, secure, and able to communicate with each other. “Certification” is a way to enforce standards. Hospitals, doctors and other eligible practitioners can earn incentive fees under the meaningful use program, by adopting certain standards and earning certification. EHRs are certified after passing tests of their functionality, reliability, security, and compliance with the standards. Certification provides assurance to purchasers and other users that an EHR system offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria established. Providers and patients must also be confident that the EHR systems they use are secured, can maintain data confidentiality, and can work with other systems to share information. Certification of EHR systems is an important step in ensuring that meaningful use requirements are met and that the benefit of improved patient care is realized.
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 health industry has existed ever since doctors bartered for chickens to pay for their services. Computers on the other hand, in their modern form have only existed since the 1940s. So when did technology become a part of health care? The first electronic health record(EHR) programs were created in the 1960s around the same time the Kennedy administration started exploring the validity of such products (Neal, 2013). Between the 1960s and the current administration, there were little to no advancements in the area of EHR despite monumental advancements in software and hardware that are available. While some technology more directly related to care, such as digital radiology, have made strides medical record programs and practice management programs have gained little traction. Physicians have not had a reason or need for complicated, expensive health record suites. This all changed with the introduction of the Meaningful Use program introduced in 2011. Meaningful use is designed to encourage and eventually force the usage of EHR programs. In addition, it mandates basic requirements for EHR software manufactures that which have become fragmented in function and form. The result was in 2001 18 percent of offices used EHR as of 2013 78 percent are using EHR (Chun-Ju Hsiao, 2014). Now that you are caught up on some of the technology in health care let us discuss some major topics that have come up due to recent changes. First, what antiquated technologies is health care are still using, what new tech are they exploring, and then what security problems are we opening up and what is this all costing.
In conclusion, technology has changed the world, as we knew it. Positive and negative come with change. The goal of the ACA, HIPPA, and EHRs is achieve positive patient outcomes, while protecting the integrity, trust and confidentiality, and decreasing health care cost. Privacy is a fundamental right of a patient, and nurses are expected to maintain confidentiality (Burkhardt & Nathaniel, 2014). A breach in confidentiality will result in lack of trust between nurse and patients. As a nurse, it is my responsibility to ensure my patients privacy, and to provide nursing care that is patient centered, not technology centered.
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).
The purpose of this paper is to discuss how Electronic Medical Records (EMR), affects healthcare delivery. I will discuss the positives and negatives this issue has on healthcare and how it effects the cost and quality for healthcare services. In addition, I will identify any potential trade-offs to cost or quality. Lastly, I will discuss how the EMR affects my job as well as any challenges or opportunities this issue presents.
Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely provide better preventive care than were healthcare professionals who did not. (page 116). From 2004, EHR has initiated, even the major priority of President Obama’s agenda is EHR (Madison & Stagger, 2011). Health care administration considers EHR as the introduction of advanced technology which can improve patient satisfaction are can increase the financial incentives of the healthcare organization. Studies have pointed out that the federal policy is proposed to transform all medical records into EHR (Hebda & Calderone, 2010).
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).