Electronic Medical Record (EMR) is a computerized database that stores all of the medical and personal information about the patient’s care and billing information from the health care providers. Today, only the medical practices and providers can implement these systems. Also there are neither known national central storage systems, nor regional sharing of information between the networks on a national or regional level (Apter, p224). This needs to be changed because it is important to be able to see this information globally. This is going to change in the near future because there are incentives given to physicians and hospitals for switching over from paper to electronic systems and within the next few years providers will be denied a certain …show more content…
Today’s healthcare is changing and more hospitals are switching over to go paperless using computers for both charting and medical records. Computers are widely accepted in personal and professional settings. It is an essential requirement for computer literacy for computers to stay in use. Numerous advances in technology during the past ten years require that nurses not only be knowledgeable in nursing skills, but also to become educated in computer technology (Hensen, 2008). While electronic medical records and charting can be an effective time management tool, some questions have been asked about how exactly this will impact the role and process of nursing. It has also questioned the ultimate effects on patient safety and confidentiality. In order to further explain these topics, I will be addressing the individual aspects of EMR’s that nurses use every day, and how they affect collaborative care. I will also go into the impact they have on the nursing role. The EHR’s purpose can be understood as a complete record of patient encounters that automates access to information. It has the potential to streamline the clinician 's workflow in a healthcare setting, while also being the principle storage place for data and information about the health care …show more content…
However, the goal to compile patient medical history so it can be readily viewed and managed in one place is yet to be fully realized. The first EHR systems, circa 1960s, were known as clinical information systems. They influenced later systems because their processing speed and flexibility allowed many users in the system at once. Around the same time, the University of Utah jointly developed the Health Evaluation through Logical Processing (HELP), one of the first clinical decision support systems (Rosenthal, 2007). Following that, in 1968, the development of the Computer Stored Ambulatory Record (COSTAR) began at Massachusetts General Hospital in collaboration with Harvard. It was designed to perform the data management functions needed by a group practice in the care of ambulatory patients. In the 1970s, the federal government began using an enterprise-wide information system built around EHR called Veterans Health Information Systems and Technology Architecture. Prior to the Information Age, medical records were all stored in folders in secure filing cabinets in doctor’s offices, hospitals, or health departments (Rosenthal, 2007). The information within the folders was confidential, and shared solely amongst the patient and physician. Today these files are fragmented across multiple sites of treatment due to the branching out of specialty centers such as
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
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
Did you ever think about how much time is spent on computers and the internet? It is estimated that the average adult will spend over five hours per day online or with digital media according to Emarketer.com. This is a significant amount; taking into consideration the internet has not always been this easily accessible. The world that we live in is slowly or quickly however you look at it: becoming technology based and it is shifting the way we live. With each day more and more people use social media, shop online, run businesses, take online classes, play games, the list is endless. The internet serves billions of people daily and it doesn’t stop there. Without technology and the internet, there would be no electronic health record. Therefore, is it important for hospitals and other institutions to adopt the electronic health record (EHR) system? Whichever happens, there are many debates about EHR’s and their purpose, and this paper is going to explain both the benefits and disadvantages of the EHR. Global users of the internet can then decide whether the EHR is beneficial or detrimental to our ever changing healthcare system and technology based living.
One organization that creates and provides standards for healthcare and the implementation of healthcare software is American Society for Testing and Materiel (ASTM). In 2004, ASTM released a standard that would change the interoperability of healthcare software forever. This standard is known as the ASTM E2369, the Continuity of Care Record (CCR) standard. The was first release of CCR was ASTM E2369-4 and was a word document that allowed interoperability between primary care physicians for the exchange of patient summary information (Sween, 2012). The CCR provides “snapshots” of a patient’s administrative, demographic, and clinical information (E31.25, 2012). The information in this snapshot focus on mainly the diagnosis an...
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 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.
Retrieved from: Ashford University Library Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521.
Over the last several years, electronic medical records are becoming more prominent in health care facilities, replacing traditional written records. As many electronics are becoming more prevalent with the invention of numerous smartphones and tablet devices, it seems that making medical records available electronically would be appropriate for the evolving times. Even though they have been in use to some extent for many years, the “Health Information Technology for Economic and Clinical Health section of the American Recovery and Reinvestment Act has brought paperless documentation into the spotlight” (Eisenberg, 2010, p. 8). The systems of electronic medical records mainly consist of clinical note taking, prescription and medication documentation,
Technology is stated as the scientific method and material used to achieve a commercial or industrial objective. To go one step further, nursing technology is using a tool to advance nursing practice. “The Institute of medicine identified that technology as a viable method of enhancing patient care delivery and improving staff productivity” Sensmeier, Horowitz (2003 page). Because inadequate nursing staff causes shortcuts to be taken, there are mistakes made that could have possibly been prevented. Errors by nursing staff were variously reported as being responsible for between 44,000 and 98,000 hospital deaths per year. Sensmeier, Horowitz (2003). Technology can have a large impact on nursing. In the past 5 to 10 years, computerized patient records have increased less than 10%. This number shows us that we are still not embracing technology to its full potential. Today in most hospital systems computerized electronic charting is being used. Many hospitals have many different systems for...
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.
William Goossen’s theory can be applied in nursing practice to develop nursing informatics skills and knowledge, as well as develop technological system competencies among nurses to collect, process, retrieve and communicate pertinent information across health care organizations (Goossen, 2000). This theory is highly applicable in addressing matters related to electronic health records, which are currently characterized with issues of privacy and confidentiality in relation to storage, retrieval and reproduction of patient health information. The model also provides broad applicability in guiding research at any clinical setting and contributes to the discipline of nursing by simplifying and enhancing documentation and storage of patient’s health information and by allowing better utilization of nursing resources (Elkind, 2009).
Electronic Medical Record (EMR) provides convenient access to the staff of the clinic. It also provides quick access to patients’ information each time staff wants to retrieve the data. Other than that, the system could help in solving record movement problems and at the same time improve the quality of the process. In terms of security, using the EMR is more secured compared to manual system as it can be restricted to certain user for example to medical officer and receptionist. The user needs to login into the system so that it can be easily monitored and identified who uses the system. As for the b...
5)The typical patient in a developing country such as India is the custodian of his/her patient record.When visiting a specality clinic,doctors first review the patient's records before they diagnose and treat a patient.What are the advantages and disadvantages of this approach?