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Privacy security and electronic health records
Privacy security and electronic health records
The effects of her implementation
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Recommended: Privacy security and electronic health records
Electronic Health Record Versus Traditional Paper Records
I spent more than half of my 25 years as a nurse using the traditional paper records. Back then, the computer was only utilized by the unit clerk to order unit supplies. All the patient’s record was stored as hard copies in the chart, from the physician’s order and progress notes to all of nursing documentation. For these reasons, I feel I am in a position to offer a valid personal comparison between paper charting and the Electronic Health Record (EHR).
Paper charting took much of the nurse’s time documenting all and everything that pertained to patient care, from admission assessment, daily nursing care, and medication administration. The thought of automation was likened
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Zhang, Yu, and Shen (2012) cited “three categories of benefits as perceived by the care staff members” (p. 690). All the following gained benefits from EHR, e.g., the care staff members, the patients, and the institutions (Zhang et al., 2012). The most cited benefit from the EHR pertains to the “convenience and efficiency in data entry, distribution, storage, and retrieval of the patient’s record” (Zhang et al., 2012, p. 690). In addition, McGonigle and Mastrian (2015) summarized “the four most common benefits… for the EHR are (1) increased delivery of guidelines-based care, (2) enhanced capacity to perform surveillance and monitoring (3) reduction in medication errors, and (4) decreased use of care” (p. 255). The nurses, in particular, perceived an improvement in the quality of patient care, communication, patient safety, and better care outcomes (McGonigle & Mastrian, …show more content…
However, to fully benefit from implementing the recommendations as outlined by the American Recovery and Reinvestment Act of 2009 (ARRA), one would need to consider some barriers that could impact the success of computerization in the health care setting. Acceptance by the senior nurses is one hurdle that the organization has to address. The resistance lies more in the lack of computer skills of the seasoned nurses. Thus, this drawback calls for providing adequate training to the nurses that would require more Information Technology (IT) staff, which consequently would impose additional cost to the hospitals. One other concern with the EHR would be maintaining the privacy and security of patient information. McGonigle and Mastrian (2015) aptly cited “Network accessibility and network availability are necessary evils that pose security risks. ... As the cloud expands, so do the concerns over security and privacy. In an ideal world, everyone would understand the potential threats to network security” (p.
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
Meaningful Use and the EHR Many new technologies are being used in health organizations across the nation, 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 an EHR incentive program called the Meaningful Use Program. This program was instituted to encourage and expand the use of the HER, by providing health professionals and health organizations yearly incentive payments when they demonstrate meaningful use of the EHR ("Medicare and Medicaid," 2014).
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,
“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.
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 ASF at my precepting healthcare facility used multiple forms of nursing documentation including both hardcopy and electronic methods. Oftentimes the hardcopy nursing notes would be discarded after the information was entered into the Computerized Patient Record System (CPRS). The task to develop an effective electronic nursing note that would eliminate the need for duplicate documentation on hardcopy forms and decrease the amount of time spent charting was initiated.
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.
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
The transition from paper based charting to electronic base charting has shown to be very complex and difficult. Not many years ago there was only one method of keeping medical records and this was utilizing paper charts. These charts, although still used in many practices today, have slowly been replaced by a more advanced method called electronic health record or EHR. The Center for Medicare and Medicaid Services (CMS), defines “electronic health records as an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include demographics, progress notes, problems, medication, vital signs, past medical history, immunizations, laboratory data, and radiology reports” (CMS.gov).
There are a number of ways in which patient care can be improved with a facility that utilizes multiple charting systems. The simplest way to provide effective quality care is to implement the EHR. A EHR is an electronic system consisting of a complete patient medical health history of past and current conditions (Keller, 2016; Menachemi & Collum, 2011). In addition, to the patient’s demographic, diagnoses, medications, treatment plans, allergies, laboratory data, immunizations, and test results. EHR decreases medical errors such as misinterpretation of clinical notes, doctors orders, not having access to paper chart that have yet to be filed or has been missed file (Keller, 2016). EHR also allows for quick and easy access to diagnostic test results and patient notes that are needed for patient care. EHR will significantly enhance patient care by reducing the amount of time it takes the healthcare team to retrieve the needed health information to deliver patient care. It will also dramatically reduce medical errors that are associated with the nursing staff manually entering doctors’
There are many advantages and disadvantages to the EHR and all of these risks and benefits are taken into consideration when establishing its use. It is vital to understand the advantages and disadvantages of the EHR in order to promote growth within the medical team and patient care. Technology adoption, training, and upgrades can be expensive but the benefits of the EHR outweigh cost. Technology is essential when optimizing the level of patient care and expanding/ growing within a company. It reduces errors and promotes effective learning. EHRs will help the members of the medical team deliver the highest level of patient centered care. Even though the training behind the use of the system might take up time and the cost to establish the system might be high, the benefits of the EHR outweigh the risks.
To effectively use the Electronic Health Record, the nurse needs to have knowledge of technology in addition to clinical competency (Linder, e.tal, 2007). This is a common barrier of implementing the Electronic Health Record. Initially, the conversion from paper charting to electronic charting is frustrating, this is particularly an issue for veteran nurses. Veteran nurses are use to a routine, documenting in pen and paper is the only method of documenting they have ever experienced. Nurses are trained and educated with a protocol-based and systematic methods of caring. The implementation of the Electronic Health Record presents a change in the way nurses care for patients (HIT, 2015). Veteran nurses that have worked in the healthcare system for over 30 years and have always used paper charts, now have to re-learn how to chart with the Electronic Health Record (Anders & Daly, 2010). Understanding the nursing related barriers of implementation of the Electronic Health Record is
Again, one goal of health information technology is safe quality patient care. The Electronic Medical Record (EMR) has gained national attention over the past decade. “The Institute of Medicine has encouraged adopting EMR to reduce medical errors, and the American Recovery and Reinvestment Act (ARRA) of 2009 established financial ...