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Electronic health record introduction
Electronic health record introduction
The importance of electronic health records
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The definition for EHR provided by HITECH is as follows: “an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff” (Tomes, 2010, p. 91). The relevance of meaningful use to health care and nursing cannot be overstated. The transformation from a paper based system to one that is fully electronic will result in interconnected and interoperable systems nationwide resulting in significant benefits to the patient (Murphy, 2010). The adaptation of nurses to these technological changes offers enhanced information access and ultimately may lead to improved patient care (Ozbolt & Saba, 2008). As the largest group of health care workers to interact
This article reviews the advantages of integrating into an EHR, the various standardized nursing terminologies currently in use and acknowledged by the American Nursing Association (ANA) which are CNC, NANDA, NIC, NOC, Omaha System, PNDS and SNOMED CT. The authors make a strong and valid point in their description of these terminologies, their integration into EHRs and how they are positively impacting nursing care, research, education and clinical practice as a whole.
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
Many new technologies are being used in health organizations across the nations, which are being utilized to help improve the quality of health care. Electronic Health Records (EHRs) play a critical role in improving access, quality and efficiency of healthcare ("Electronic health records," 2014). In order to assist in expanding the use of EHR’s, in 2011 The Centers for Medicaid and Medicare Services (CMS), instituted a EHR incentive program called the Meaningful use Program. This program was instituted to encourage and expand the use of the HER, by providing health professional and health organizations yearly incentive payments when they demonstrate meaningful use of the EHR ("Medicare and medicaid," 2014). The Meaningful use program will be explored including its’ implications for nurses, nursing, national policy, how the population health data relates to Meaningful use data collection in various stages and finally recommendations for beneficial improvement for patient outcomes and population health and more.
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.
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.
One important feature of this class is the emphasis on EMR/ EHR. In the course of this class I have learned a lot about the importance of electronic health record and the laws governing it. Perhaps my biggest take away in the course of researching for this class is how vulnerable electronic health record is. It is generally believed that health records are safe and secured but in this modern time it is as vulnerable as any online data. Though there are laws governing the protection of electronic health record and electronic medical record under HIPPA and the Affordable Care Act yet hackers still find a way to penetrate health organizations health data to steal 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 records (EHRs) Has improved the quality and safety of patient care and achieve real efficiencies in the healthcare delivery system throughout the years. EHRs are the tools through which physicians, nurses, and other staff enter, view, and share the information required to deliver high quality care. it is vital in clinical decision making for patients and physician; therefore, the U.S. Department of Health and Human Services provides Healthcare industries with The Research-Based Web Design and Usability Guidelines. In the user-interface (UI) design community this is partially addressed through the establishment of interactive patterns and collection of building blocks that represent recurring solutions to common design problems.
Electronic Health Record systems (EHR) are essential to amending health quality and managing health care distribution, whether in an extremely immense health system, hospital, or primary care clinic. The U.S. Department of Veterans Affairs (VA) has developed and perpetuates to maintain a strong EHR kenned as VistA - the Veterans Health Information Systems and Technology Architecture. This system was designed and developed to strengthen a high-quality medical care environment for the military veterans in the United States. The VistA system is in maintained today at hundreds of VA medical centers and outpatient clinics across the country. (http://worldvista.org/AboutVistA)
An electronic health record (EHR), or electronic medical record (EMR), refers to the systematized collection of patient and population electronically-stored health information in a digital format. It details medical problems, medications, vital signs, patient history, immunizations, laboratory data and radiology reports, progress notes .These records can be shared across different health care settings. It resides on an enterprise information systems and is exchanged via electronic networks.EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.why is it needed? It seeks to be a complete record of a patient that can follow him/her from setting to setting increasing knowledge and consistency. It allows providers to obtain a complete picture of a patient and allows firms to automate and streamline workflows. It could improve patient and financial outcomes via evidence-based decisions, quality management, data mining, tracking, and reporting.
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...
Canada provides a universal health insurance coverage plan (Medicare) to its citizens. This includes physician visits and specialist services by referral from a physician. Depending on the province, the coverage may include prescription medication and other services. Services like dental and prescription glasses may be obtained through other private insurance plans. Although the Medicare provides universal access, owing to the climatic and terrain conditions of Canada, one may find it difficult to access the various health care services.
The federal government has encouraged EHR use in hopes that it will significantly improve patient care. There is the intent that electronic health records will allow any provider access to important patient health information no matter where the patient is, while “creating a comprehensive national electronic health information network that leads to a reduction in the duplication of tests, an improvement in the cost-effectiveness of interventions, and the ability to compile a comprehensive patient history” (McBride, Delaney, Tietze, 2012). While the implementation of EHR’s has good intent, an important question is, “How are the implementation of EHRs having an effect on emergency nursing and patient care?”
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.