Electronic Health Records: Annotated Bibliography

Health providers across America are using Electronic Health Records systems to keep up with patient’s health information. Long hours of filing and writing patients health information manually has become a thing of the past. The Electronic Health Record system, known as EHRs, has changed how patients and health providers communicate as a whole. It has taken information technology to a different spectrum, and has helped patients become more aware of their health history and health conditions. Throughout the years, EHRs systems have been crucially ridicule in the medical world, due to lack of knowledge, high expenses, and apprehension among health providers. Because there will always be challenges when new technology starts to expand in any type of establishment. I believe that EHRs serves a great purpose in health care despite its delays.

Technology has enabled us to make advances in patient care, and thus increase healthy patient outcomes. Nurses are constantly adapting to new technology, and need to learn to work with their IT department to successfully maneuver their electronic system. This paper will provide details of EHR implementation, and the goals of health implementation technology.

Health information technology is a familiar entity for most working nurses in the year of 2017. Many nurses, have lived through the transition from paper charting to online charting. This transition has not always been a progression of ease. Change is never easy. The process of paper charting with pen and paper and the use of paper medication administration records have been the routine process for many years. With the new onset of the electronic health record (EHR) many processes have become easier, safer, and more efficient while some tasks have become more complicated, confusing, and more time consuming. The goal of this paper is to describe the electronic health record system, expand on the essence

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

As patient information is readily available in the electronic record, it makes health care provider make better and quicker choices and decisions. These decisions can be based on evidence base care that is supported through data that is gathered from the patient’s records. EHR improves patient safety by providing access to information, eliminating gaps of communication among the different providers, decrease redundancy, and reduces duplication in testing. EHR has benefited health care and at the same time create positive outcomes for the nurses. Some of the positive outcomes for nurses are; comparison of previous to current data, improves documentation of the quality of care, allows recognition of the work done in measurable units by nurses, and reduces redundancy with baseline demographic data (Hebda & Czar, 2013). Data that is summarized through the EHR can evaluate performance management and look at quality issues. Along with those features, EHR can potentially increase efficiency, improved quality of care, standardize documentation, increase clinical workflow, and improved overall outcomes for

In the last decade of USA medical history there have been little to no change in medical errors in regards to improvement of care. Meaningful Use, Electronic Health Records and Health Information Technology are practices and programs that can be possible solutions for this issue. The goals of meaningful use include improving quality, safety, efficiency, and to reduce health disparities, improve care coordination and ensure adequate privacy and security of personal health information (Hoyt,2014). With meaningful use, there are three stages: stage one begins the process of capturing date and sharing the information. Stage two is advancing the data processing and sharing and building off of the first stage. Stage three is the examination of the outcomes. Meaningful Use is defined under the Center of Medicare and Medicaid (CMS) and is essentially an incentive program through the government to create a health system that is run electronically and provides higher quality of care through technology. Since the goal is to create safer and higher quality through HIT by providing an incentive for EP’s to further develop their use of the technology there must be a time line in place in order to know whether the Ep’s hitting the requirements. This year, 2014, is originally a major year for Meaningful Use however, with changes in the time line, the cost of HIT, and the increasing of objectives can lead to major complications in the initial timeline created.

For a nation to be technologically advanced, the United States (U.S.) is having a hard time overcoming the dark era of utilizing hand written scripts, progress notes, and paper records. In comparison to other countries, the U.S. is lagging behind in the health care system. Even with all the improvements that have been made recently, the U.S. ranked last in 2014 in areas such as access, efficiency and equity compared to Australia, Canada, France Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom (Davis, Stremikis, Squires, & Schoen, 2014). Now, as our nation is trying to improve the quality, access, and proficiency of our health care, concerns have been raised whether the new policies are adequate enough for privacy amongst sharing and obtaining health information. This paper was put together to give background information on how the electronic medical record came about and whether privacy is a major concern amongst the American population.

This paper provides a discussion of the Electronic Health Record for healthcare, explains why it is important for nursing to have a standard nomenclature for nursing care, and compares and contrasts two of the nursing terminologies currently recognized by the American Nursing Association.

Electronic health records will be electronically accessible to vendors and clients. To protect confidential information a security code must be used to access information. The Institute of Medicine identified six goals for health care; medical care should do no harm, be valuable, patient-focused, relevant, fruitful, and unbiased. (National Academies, 2013). EHR can help increase patient-focused care; the patient will be able to view their records online and assist in guiding their care. When records are accessible online patients can see them and manage diseases, collaborate care with providers, and improve patient to provider communication (Ricciardi, Mostashari, Murphy, Daniel, & Siminerio, 2013). Patients that are well-informed about their care have better health outcomes compared to uninformed patients. Patients who are involved in their care are less likely to experience adverse effects, to be admitted to the hospital, and have a medication error from lack of collaboration with their provider (Ricciardi et al. 2013). For providers to receive funds under the meaningful use incentive to purchase electronic equipment, they must show medical decisions are patient driven. (Ricciardi et al. 2013).

Some of the forces inside and outside health care that are driving a move toward a greater use of informatics are national forces, nursing forces, healthcare consumer empowerment, patient safety, and cost. The National forces aim is to create electronic health records (EHR), and the creation of national coordination for healthcare information and technology. With the use of electronic health records many patients that have more than one provider will benefit because

The meaningful use law was written into legislation with the sole purpose of providing healthcare providers with funding for implementing healthcare information technology, electronic health records, protecting patient’s health information, and provides patients with greater access and control over their protected health information. Derived from the Health Insurance Technology for Economic and Clinical Health Act (HITECH) that provides funding and incentives for the implementation of electronic health records. Title IV of division B of the ARRA is considered part of the HITECH Act. It addresses Medicare and Medicaid EHR and provides financial incentives to healthcare providers and hospitals that adopt and engage in the “meaningful use” of the electronic health record technology. If this legislation made known, and end-users have a better understanding of the legislation fears and obstacles in adopting this anticipated change can be overcome.

The major change from traditional systems to electronic record systems in the healthcare field within the last couple decades has made a huge impact. Patient records, risk management, planning, staff, and more in the organization are affected by the IT staff. “The penetration of Internet access, mobile technologies and social networks collectively offer a future in which it is possible to deliver highly personalized care without necessarily having to do it in person, or even with a doctor.”(Healthcare IT News, n.d.) Many hospitals use paper records for patients long after electronic record technology was available. According to forbes.com in an article published two years ago, less than 2 percent of all healthcare organizations within the United States had and properly deployed information systems.

Electronic health record is a type of medical instrument which is electronically operated. The electronic health record contains patient’s information over time which is stored by the provider concerning the medication, all the progress notes and the problems concerning the patient over time are kept. The data should be standardized in order to be kept in HER system whereby care should be highly taken more so in the uniformities of the data. There should be a common language used in the HER and maintained standards to allow good communication in the electrical health records. There are different codes found in electronic health records which enable this system to function effectively. This paper therefore provides information about electronic health record codes. It also provides more information on the similarities and differences of the different HER codes

The code of ethics for nurses provides a framework on ethical principles that nurses are supposed to follow while providing patient care. Under this code, nurses are not allowed to pry into information on patients not directly under their care, and they could not share any patient information to individuals who are not privileged to know such information. (American Nurses Association, 2015). Ethical issues related to electronic health records (EHRs) are extremely beneficial to clinicians, patients and an organization. This is because it not only increases access to health care, but it does reduce costs, improves the quality of health and care provided. The EHR is accurate to an extent, however its positive effects on productivity, should not underestimate the negative effects that ensues from using EMR. There are some Electronic health records that create conflict among several ethical principles. (American Nurses Association, 2015).

Electronic health records (EHR’s) have many advantages, but there are plenty of disadvantages. EHR’s were created to manage the many aspects of healthcare information. Medical professionals use them daily and most would feel lost without it. Healthcare organizations were encouraged to adopt EHR’s in 2009 due to the fact that a bill passed known as The Health Information Technology for Economic and Clinical Health Act (HITECH Act). “The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice”, (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012).