Introduction
As the world is becoming more advance in the use of technology, new scientific trends are emerging in management concentrations in the health care industry. Health care maintains and improves physical and mental health by using medical services. Health Information Technology is the use of technology in health care. Technology involved with this includes electronic health records, mobile health, sensors technology, telemedicine, etc. Keeping proper documentation using Electronic Health record technology can improve an individual’s health safety when it comes to the application process in documentation and communication. Electronic health record, commonly abbreviated as EHR, is the use of technology in reference to health related
…show more content…
It is the new and improved version of the traditional paper record of an individual that has been filed and stored in a filing cabinet. Over time the records are kept and maintained electronically using a compute based system. According to CMS, “Clinical data relevant to that persons care, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports “ (pg 1). The system automatically gathers information based on the timeline of a patients history. The Electronic health records has different interfaces that can support quality managements, provide decision support, various outcomes. Using Electronic Health Records are beginning to be the next major innovation in the continuation of the progression of healthcare to strengthen the bonds between clinician facilities and patients, by providing better decisions and provide proper care to an …show more content…
In addition, systems can maintain the record of refilling prescriptions. The use of HIT does not only benefit medical professions, it benefits patients as well by allowing them to conveniently have access to their own personal health records. EHR allows patient to access and manage their personal health records anywhere at anytime with the benefit of technology.
HITECH
• Provides a basic level of interoperability among electronic health records (EHRs) maintained by individual physicians and organizations
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 case study by Elizabeth Layman (2011) is a very comprehensive compilation of the implementation of electronic health records, in relation to the Health Information Services Departments. Through this study Layman documents the conditions to be implemented to achieve satisfactory application of the change-over from the conventional pen and ledger system to computer documentation of patient’s records maintained by health networks.
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.
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.
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...
Electronic health records is medical information recorded on computers, the data consists of a variety of data, medical history, medication, allergies, diagnoses, immunizations, labs, radiology, vital signs, billing information, and personal statistics weight and age. The EHR is designed to help with medical errors. It helps reduce errors with allergies to a medication. Also help with reading legibility and eliminate the lost forms and paperwork. It allows for the patients history to be viewed by several doctors. Doctors or nurses can update information on your record.
The EHR is defined 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 than one healthcare organization” (Fahrenholz, C. G. & Russo, R., 2013b). The Office of the National Coordinator for Health Information Technology (ONC) has published a list of required items an EHR must have to satisfy the complete EHR definition. According to the ONC, the EHR must include, for both ambulatory and inpatient systems: computerized provider order entry, demographics, a problem list, a medication list, a medication allergy list, clinical decision support, transitions of care, data portability, clinical quality measures, authentication, access control and authorization, auditable events and tamper resistance, audit reports, amendments, automatic log-off, emergency access, end-user encryption, integrity, drug-drug and drug-allergy interaction checks, vital signs, body mass index and growth charts, electronic notes, drug-formulary checks, smoking status, image results, family health history, patient list creation, patient-specific education resources, electronic prescribing, clinical information reconciliation, incorporation of lab tests and values/results, immunization information, transmission to immunization registries, transmission to public health agencies-syndromic surveillance, automated measure calculation, a safety-enhanced design, a quality management system and be able to view, download and tra...
My perception of case is that the use of electronic health records will improve the quality of healthcare for healthcare professional and patients. It will allow patients to view their information online. It will also allow healthcare professionals, with consent, to exchange
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,
We can look at the patient’s allergies, their vital signs, and even their most recent weight which is important when we have a patient with Congested Heart Failure. Being able to share a patient’s medical record and all their health care encounters is so vital in the complete care of a patient. Being able to assess a patient’s medical record electronically is also important when it comes to prescribing medications because it can alert the provider to potential conflicts with other medications that the patient has been prescribed. And if a patient comes into the emergency room unconscious from an accident, the provider can still look up the patient and adjust care as needed. The electronic medical record is important in the transition of care of a patient from one provider to another. For example, when a patient is hospitalized and then discharged, they are asked to follow up with their primary care doctor within two weeks. With the provider being able to consider the patient’s electronic medical record they can see what care the patient received while they were hospitalized and vice versa, the emergency room provider is also able to consider the patient’s electronic medical record to see the care plan for the patient and the care the patient has been receiving from their primary care provider. According to HealthIT, Electronic Medical Records can reveal potential safety problems when they occur, helping providers avoid more serious consequences for patients and leading to better patient outcomes. Electronical Medical Records can help providers quickly and systematically identify and correct operational problems. In a paper-based setting, identifying such problems is much more difficult, and correcting them can take
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.
For centuries, health care systems have depended on paper-based records, and the steady move towards modernized systems has been occurring for no less than two decades in western social insurance frameworks. Nevertheless, the utilization of mechanized frameworks in human services has not been broad as the instance of different segments, for example, transportation, money, retail commercial ventures and assembling. Likewise, computerized systems executed in health care systems have been utilized fundamentally for administrative functions rather than clinical practices. Emergency Medical Records have various points of interest in today’s society. Milewski and Anurag (2009) assert that EMRs are the favored record management system because of the
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...