Electronic medical records have been around for more than 30 years, but since 2010 they have become widely adopted throughout the healthcare industry. Electronic health records (EHRs) are comprised of many components that work together to “automates access to information and has the potential to streamline the clinician's workflow” (“Electronic Health Record,” 2012). The system allows more efficient and accurate patient care while reducing costs in the long term for healthcare practices. Small healthcare practices have moved slowly in adopting electronic health record (EHRs) systems for their practices, their lack of readiness will cause the organizations problems in transitioning to the implementation of EHRs. This research paper will discuss why we need electronic health records (EHRs), the advantages of EHRs and some factors associated with rolling out successful electronic health records (EHRs) systems. Implementing electronic health record (EHRs) systems can help small healthcare practices reduce costs and increase the efficiency of treatment for patients.
Why do we need EHRs
Electronic Health Records (EHRs) are electronic versions of patient health information that is generated and managed by health information management systems. Patient health records include patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (“Electronic Health Record,” 2012). Electronic health records allow: easy backup of information, patient records to be accessed remotely, easy storage of information, reduction in office space, and many other capabilities. According to Menachemi and Collum (2011), “three particular functionalities hold great promise...
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Electronic Health Records. (2012). Centers for Medicare & Medicaid Services. Retrieved from http://cms.hhs.gov/Medicare/E-Health/EHealthRecords (Corporate author; Technical report; Published on the Internet)
Henricks, S.G. (2011). “Meaningful use” of electronic health records and its relevance to laboratories and Pathologists. Journal of Pathology Informatics. 2:7. doi: 10.4103/2153-3539.76733
Menachemi, N., & Collum, T. (2011). Benefits and drawbacks of electronic health record systems. Risk Management Healthcare Policy. 4: 47–55 doi: 10.2147/RMHP.S12985.
Rao, S.R., DesRoches, C.M., Donelan, K., Campbell, E.G., Miralles, P.D. (2011) Electronic health records in small physician practices: Availability, use, and perceived benefits. Journal of the American Medical Informatics Association. 18:271e275. doi:10.1136/amiajnl-2010-000010.
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
Healthcare professionals associated with medical billing and coding know the progress the technology has made so far. In the last few decades, medical billing and coding has switched from being a paper-based system to a computerized format. Under HIPAA laws, medical practitioners had to develop new software in order to send out electronic bills. With the advent of electronic medical records (EMR), with one touch of a button, doctors, Nurse Practitioners and PAs can gain access to all the care a patient has ever received from every healthcare facility the patients visited previously and can figure out possible illnesses. This enables statistical documentation of the population as a whole as well. EMR can also make the healthcare system more transparent and allow integration with reimbursement data. As the healthcare system changes, this will prevent unnecessary costs and make it easier to get the reimbursements needed to treat a patient.
The main purpose of EHRs is to mainly exchange health information electronically to help improve quality and safety for patients. Four pros of EHRs is to provide accurate and recent information of the patients, allow for quick access to the patient records, share the health information securely, and make patient records and notes legible. These four points are important and necessary because the goal overall is to improve public health. Patient information should always be updated and current. Health professionals need to easily have access to patient records to either update them or verify the information. Also, health professionals can now avoid any discrepancies with electronic records verses when records were completely on paper.
“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.
The transformation of paper based health record to electronic health record is not an easy step for any providers or organizations but is a major step in the process of providing improved and efficient patient care. Every healthcare organization should have the vision of adopting EHR because it provides numerous benefits not only to providers but also to patient. It is the vision of every healthcare provider to offer the best health care possible. So implementation of EHR is a necessity.
Tan & Payton (2010) describe the electronic health record (EHR), which dates back to the 1950s. These computer-based patient records have evolved into complex systems with many capabilities. They were designed to provide healthcare professionals with a comprehensive picture of a patient’s health status at any time and are meant to automate and streamline the workflow of the healthcare professional (Tan & Payton,
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.
Miller, R., & Sim, I. (2004). Use of electronic medical records: Barriers and solutions. Retrieved June 29, 2011, from http://content.healthaffairs.org/content/23/2/116.short
Over the years, healthcare facilities have acted like a storehouse for patients’ medical records, uninterested and unable to distribute clinical data to anyone beyond their organization. The EHR, started in the 1960s under the name of "computerized-based patient record" (CPR), became known as "electronic medical records" (EMR) in the 1990s and today it is known as electronic health record (EHR).The target of the Department of Health and Human Services (HHS) is to incorporate the EHR and use it in a "meaningful" way to improve the quality, efficiency, and safety of patient care delivery; to engage patients in their personal health record; and to improve care coordination. Equally important, the "meaningful use" of the EHR system intends to build a bridge to other systems by creating an interoperability of health information while implementing quality care throughout. However, this interoperability can only be accomplished when the receiving system and the user fully understand how to apply these exchanges.
An Electronic Health Record is defined by NEHTA Acronyms, Abbreviations & Glossary of Terms (p22, 2005) as “an electronic longitudinal collection of personal health information, usually based on the individual, entered or accepted by healthcare providers, which can be distributed over a number of sites or aggregated at a particular source. The information is organized primarily to support continuing, efficient and quality health care. The record is under control of the consumer and is stored and transmitted securely”
Currently, Kaiser Permanente, a nonprofit organization has already begun to implement the practice of electronic medical records. Kaiser Permanente patients have the privilege of sharing their medical history with each medical provider seen during their Kaiser membership. Depending on the level and type of information needed, every healthcare professional patients have encounters with within their geographical region will have access to notes, prescriptions, procedures, and diagnostic tests at the click of a mouse, to effectively and proficiently render care. All medical documentation provided to Kaiser Permanente from othe...
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.
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 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).