After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital signs, medical history, immunizations, laboratory data, radiology reports and billing information (www.cms.gov). The EHR’s purpose can be understood as a complete record of patient encounters that automates access to information and has the potential to streamline the clinician's workflow in a healthcare setting. It also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting (www.cms.gov; “Electronic Health Records”, 2010). One of the main purposes of the EHR is to improve and strengthen the relationship between clinicians and their patients. It also is an attempt to reduce patient suffering due to medical errors and aid healthcare workers to make better decisions in providing quality care. The collection of data can also prevent test duplications, delays in treatments and procedures, prescription interactions, automate templates and/or forms and improve clarity... ... middle of paper ... ...p://en.wikipedia.org/wiki/Health_Level_7 Medical record privacy. (2010, August 9). Retrieved August 10, 2010 from http://epic.org/privacy/medical/ Tegan, Anne, et al. "The EHR's Impact on HIM Functions." Journal of AHIMA 76, no.5 (May 2005): 56C-H. Sprague, Lisa. (2004, September 29). Electronic health records; How close? How far to go?Retrieved August 10, 2010 from https://www.nhpf.org/library/issue-briefs/IB800_EHRs.pdf Leavitt, Mark. (2008, September 25). The Positive impacts of certification – bigger than anyone realized. Retrieved August 11, 2010 from http://ehrdecisions.com/2008/09/25/the-positive-impacts-of-certification-%E2%80%93-bigger-than-anyone-realized/ Morton, Mary. (2010). EHR acceptance factors in ambulatory care; a survey of physician perceptions. Retrieved August 11, 2010 from http://library.ahima.org/xpedio/groups/public/documents/ahima
Friedman, D. J., Parrish, G., & Ross, D. A. (2013). Electronic Health Records and US Public Health: Current Realities and Future Promise. American Journal of Public Health, 103(9), 1560-1567
To be considered meaningful users of the EMR, the qualified applicant must use clinical content that is consistent and standardized across systems and healthcare settings, use decision support tools such as alerts and reminders, have the ability to collect and store raw data from documentation that can be used for reporting purposes, collect and report data to the state. Reporting of data will help to improve public health and awareness and provide sharing of information between systems (Tripathi,
It was just yesterday when Electronic health records was just introduced in healthcare industry. People were not ready to accept it due to higher cost and consumption of time associated in training people and adopting new technology. Despite of all this criticism, use of Internet and Electronic Health records are now gaining its popularity among health care professionals, as it is the most effective way to communicate with patient and colleagues. More and more hospitals and clinics are getting rid of paper base filling system and investing in cloud base storage.
Kutney-Lee, A. (2011). The effect of hospital electronic health record on. NCBI, 41(11). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3236066/
“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.
Healthcare Information and Management Systems. (2012). Electronic Health Record . Retrieved March 19, 2012, from HIMSS : http://www.himss.org/ASP/topics_ehr.asp
EHRs come with benefits and drawbacks, some of the benefits include faster care, efficiency of communication between other health professionals and saving of space due to digital records. In contrast some drawbacks include loss in productivity, learning curve, and financial issues. All the articles listed below contain further details of the benefits and drawbacks that come with EHRs and how they can be of use in the near future.
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.
An Electronic Health Record is defined by NEHTA Acronyms, Abbreviations & Glossary of Terms (p22, 2005) as “an electronic longitudinal collection of personal health information, usually based on the individual, entered or accepted by healthcare providers, which can be distributed over a number of sites or aggregated at a particular source. The information is organized primarily to support continuing, efficient and quality health care. The record is under control of the consumer and is stored and transmitted securely”
EHRs are “a real-time, patient-centered” records that make health information available promptly and bring any patients’ health information together in one place such as medical history, medications, diagnosis, laboratory test results, immunization records, allergies and even medical images, and many others. The use of electronic health records (EHRs) continuously increases. An ability to collect secure patient data electronically, and supplies the information to the providers upon a request is one of the features in EHR. The system can also bring together information from more than one health care organization and any past and current clinical services of the patient that helps the health care professionals in providing quality services. Within this scope, EHR benefits health care providers to enter orders directly into a computerized provider order entry (CPOE) system, provides tools in decision making like, alerts, reminders, and provides access to the new research findings and evidence-based guidelines (Wager, Lee, & Glaser, 2013, pp. 134-37). The United States is creating large investments to boost the adoption and use of interoperable electronic health records (EHRs)
...ck of EHR interoperability, there are inevitably several challenges that must be considered in order to ensure that these solutions are successfully carried out.
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.
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...
Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely provide better preventive care than were healthcare professionals who did not. (page 116). From 2004, EHR has initiated, even the major priority of President Obama’s agenda is EHR (Madison & Stagger, 2011). Health care administration considers EHR as the introduction of advanced technology which can improve patient satisfaction are can increase the financial incentives of the healthcare organization. Studies have pointed out that the federal policy is proposed to transform all medical records into EHR (Hebda & Calderone, 2010).