In the healthcare environment, clinical documentation is the collection of information that refers to patient’s electronic health or medical record. There are many advantages of using informational health records, “health care environment is experiencing an explosion of knowledge that requires standardization to collect, store, achieve, retrieve, process, analyze, and exchange vast amounts of health data , (pg. 252).” In addition, the clinical documentation is important to collect medication orders, care plans, consults, laboratory data, and client outcomes. These records are used to facilitate structured communication between nurses and other health professionals to improve the delivery of quality care. Thus, clear communications throughout the healthcare organization is very important to the well-being of the customers and professionals that provide
This model is designed to provide a guideline to healthcare professionals as well as healthcare related researchers in preparing, acquiring and transitioning EHRs. Updated version of HL7 allowed interoperability among electronic Patient Administration Systems (PAS), Electronic Practice Management (EPM) systems, Laboratory Information Systems (LIS), Dietary, Pharmacy and Billing systems as well as Electronic Medical Record (EMR) or Electronic Health Record (EHR)
Case Study I Prior to implementation of Epic, Mt Sinai Medical Center (MSMC) was using a paper based system which caused difficulties for the staff and caused discontinuity in care. Pertinent Information was often unavailable to the staff and caused discontinuity of care. Furthermore, the integrity of the records was often questioned due to the lack of information available to the providers. Implementing Epic improved continuity of care such as providers were able to see the updated and current medications, diagnosis and receive updates on patient. Furthermore, the implementation of electronic health record system(EHR) improved data collection and provided a metric to measure quality of care provided to patients.
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). Although they are reliable, paper medical records are becoming a thing of the past, while electronic medical records are among one of the new advancements in our technological world. Both paper c... ... middle of paper ... ...n alternatives. International Journal of Technology Assessment in Health Care, 21(1), 126-31. Retrieved from http://search.proquest.com/docview/210350660?accountid=9720 Menachemi, N. & Collum, T. (2011).
Benefits and Barriers of Electronic Health Records “There are two concepts in electronic patient records that are used interchangeably but are different-the electronic medical record (EMR/EHR) and the electronic health record. The National Alliance for Health Information Technology (NAHIT) defines the EHR as the electronic record of health-related information on an individual that is accumulated from one health system and is utilized by the health organization that is providing patient care while the EMR accumulates more patient medical information from many health organizations that have been involved in the patient care. The Institute of Medicine (IOM) has been urging the healthcare industry to adopt the electronic patient record but initially
It is pertinent to note that ICT gives room for technological convergence in that various communication channels or platforms are integrated in it. This has opened the way for health enlightenment in various forms such as podcasts, short videos, blogs and so on. The limitless coverage of the internet allows these enlightenment efforts to be accessed all over the world enhancing global health. The information system of any health center will not function effectively without Information and Communication Technology (ICT). In other words, ICT is the backbone of the current information system.
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. Adoption of Meaningful Use in Today’s Healthcare society The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009.
This limits many providers because many practices are not able to provide the necessary capital to start such a program. In addition to medical practices not having the necessary capital, providers must then work with a decreased patient load with the anticipation of possible reimbursement in the future.3 These points make it clear that the transition to a PCMH model would require hard work and commitment from the involved providers to make it
Introduction Regional Health Information Organization also known as RHIO is the Health Information Exchange Organization which sits under the Nationwide Health Information Network. NHIN describes technologies, standards, laws, policies, programs, and practices that enable health information to be shared. The purpose of the RHIO organization is to facilitate a health information exchange; which is the transfer of healthcare information electronically across organizations. The reason for HIE is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology. Pros & Cons The goals for NHIN are to achieve nationwide health information exchange through the vision of utilizing information technology solutions to cut costs, avoid medical mistakes, and improve health care in America through the goals of informing clinical practice, interconnecting clinicians, personalize care, and improving population health.
It has several benefits because it allows tracking the data over time and identifying and monitoring and improving as it allows the patients to identify the patient visits and screenings. Electronic health record will serve as the source for the electronic medical record. There is a difference between the emr and ehr where electronic health record is used to share information from all providers. The data stored in the ehr can be modified, updated, and share by the trusted providers. Risk assessment in such cases will have to make up an enterprise for medical practice called as Medco.