Similarly, Murphy (2014) has discussed some feature of CDSS that will influence its success and make it more effective. - Computer based generation of decision support - Automatic provision of decision support as port of clinical workflow - Provision at time and location of decision making. - Provision of a recommendation, not just an assessment. - Provision of decision support results to both clinicians and patient - Systems providing advice for patients in addition to practitioners. On the other hand, Sittig et al (2008) have discussed the grand challenges of CDS and placed them into following three large categories: A) Improve the effectiveness of CDS interventions: 1) Improving the human-computer interface 2) Summarizing patient level information (2015) have emphasized the role of CDSS for improving diagnostic accuracy and achieving precision medicine. EHRs have laid foundation for CDSS and thus to achieve improved outcomes via EHR use, the best methods to digitize the massive amount of data must be identified. According to the authors, CDSS are designed to assist the physician-patient encounter at multiple points from initial consultation to diagnosis to follow-up with expectations that properly equipped CDSS will significantly benefit patient care at all levels. The authors stress the need for collaborative efforts from academic and industry sectors along with the application of expertize in electronic health/medical records (EHR/EMR) to achieve efficacy in patient care and minimize costs. Some of the possible benefits of proper implementation and meaningful use of EHR to the CDSS include: decrease in operating costs, decrease in error rates, and increase in favorable patient outcomes, increase in completeness of patient encounters, encouraged patient questions, reduced confusion due to illegible handwriting, and boosted confidence of clinicians in EHR system. On the other hand, some of the major barriers and disadvantages of EHR adoption include: cost effectiveness, data security concerns, and sharp learning curves, insufficient EHR training, workflow disturbances due to system crashes, increased duplicate entries, etc. (Castaneda et al., 2015). Literature Review and Discussion: Evolving Roles of Librarians
Similar to Global Positioning Systems (GPS) provide drivers with directions, detours, alternative routes, and alerts, Clinical Decision Support (CDS) systems provide health care professionals with guidance for important decisions associated with patient care. These systems have many capabilities including synthesizing patient information, suggesting diagnostic tests, providing alerts for life-threatening situations, recommending treatment options, and providing relevant evidence and best practices. Nonetheless, just as GPSs, CDS systems are not usually perfect as evident in the ongoing evolution of their design specifications and functionalities. Some of the major issues that are still evolving for CDS systems include alert fatigue and integration of evidence-based practice (EBP) resources and clinical guidelines. One of the major areas that can benefit from the adoption and integration of clinical decision support systems is community health nursing. These systems can be used together with evidence-based medicine to help improve the quality of health and patient care in community health 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
Woo, A., Ranji, U., & Salganicoff, A. (2008). Reducing medical errors with technology. Retrieved March, 2012, from http://kaiseredu.org
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.
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.
“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 Record (EHR) is a digital collection of patient health information instead of paper chart that captures data at the point of collection, supports clinical decision-making and integrates data from multiple sources in any care delivery settings. The health record includes patient’s demographics, progress notes, past medical history, vital signs, medications, immunizations, laboratory data and radiology reports. National Alliance for the Health Information Technology defines EHR 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
Most importantly, Stage 2 of Meaningful Use has been distinctly defined as SNOMED CT, which is the main language used for specifying the problems within a patient’s chart. Using SNOMED CT to communicate with a common language with other healthcare providers enables both providers and electronic medical records to increase the delivery of a safe and productive environment. SNOMED CT also has the ability to improve the
This paper will showcase the major components of clinical decision support, as well at take a look what is analysis of evidence-based medicine and describe how computerized systems can be used to support evidence-based medicine practice. Clinic decision-making provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care (Richardson & Ash 2011).
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.
Provides a basic level of interoperability among electronic health records (EHRs) maintained by individual physicians and organizations
parental advisory warnings on the CD's. This lets the consumer know that the CD they
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).