Electronic Health Records In Informatics

In a healthcare world that operates on stringent budgets and margins, we begin to see the need for a higher capacity healthcare delivery system. This in turn puts pressure on the healthcare organizations to ensure higher standards of patient care, and compliance with the reform provisions. However, these are the harsh realities of today’s healthcare environment, a setting in which value does not always equal quality. The use of technology can help to amend some of this by providing higher capacity care without compromising quality; this can be done with the use of such technology as electronic health records (EHRs). This paper will aim to address how EHRs influence healthcare today by expanding upon topics such as funding sources, reimbursement methods, economic factors, socioeconomic factors, business influences, and cost containment.

In 2009 the federal government established The Health Information Technology for Economic and Clinical Health Act (HITECH) and supported the national implementation of certified Electronic Health Records (EHRs); funded by the Centers for Medicare and Medicaid’s (CMSs) ‘Meaningful Use’ Incentive program. “An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative, clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.” (Centers for Medicare & Medicaid Services, 2012) The purpose of the EHR is to manage and automate clinical workflows and to improve the quality of care by eliminating

In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.

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

Electronic Health Records (EHRs) is another version of a patient’s medical history, that is maintained by the healthcare facilities or provider over time, and may include all of the key administrative clinical data relevant to that persons care under particular healthcare facilities, including demographics, progress notes, medication, x-rays, surgical history, and etc.(CMS,2012). While the adoption of the electronic health record system seems promising for the healthcare community and having a positive impact on the HIM field with better care and decreased in healthcare cost, and other promising aspects. However, poor EHR system design and improper use can cause EHR-related errors put at risk to honesty of the information in the EHR; causing or leading healthcare facilities and hospital to break that confidential bond they have with the patient. This will cause EHRS to have errors that endanger patient safety or decrease the quality of care that the patients expect from the hospital or healthcare facility (Bowman, 2013). In the paper I will discussed the topics along the lines like managing the Transition from Paper to EHRs, EHRs to redefine the role of doctors, and other ways how EHRs impact will have on the HIM community.

Healthcare have came a long way in adopting and integrating technology and HER systems in a daily basses. On a studies reported on HealthIT.gov, the majority of physicians believe that electronic medical records provide a better view of their patients’ total health – allowing for better diagnoses while reducing the chance of medical errors ("HealthIT.gov | the official site for Health IT information," n.d.). The major importance EHR that stands out is to improve the quality and safety of care. IN addition it allow a better and safe transition of care as well

The use of IT in the healthcare field has been a strategic focus for necessary improvement that stands to enable more cost effective, higher-quality, and far safer patient care according to the Committee on Data Standards for Patient Safety (2003). The National quality forum conceptualized the idea of meaningful use to the nursing fraternity and believed that they were the most critical link in patient care and health delivery and hence technology tools of EHR would be best used by them The purpose of the electronic health records was to improve the health of population, coordination of care, safety improvement in patients undergoing critical and long term care, and patient and family engagement in timely access of

The use of electronic health records (EHR) aims at improving the quality and safety of patient care. An electronic health record (EHR) is an electronic version of the patient’s entire medical history including past diagnoses, treatments, and current medications being taken. There has been a rise in the conversion to EHR from paper records because these electronic records can track patient data over time and monitor parameters such as trends in vital signs over time or vaccination history, all which contribute to the improvement in the quality of patient care being delivered (Department of Health and Human Services, 2014). EHR’s are used currently to make more efficient, comprehensive decisions about patients, because there is more information available at the fingertips of the providers. By adopting EHR’s, it can provide health care providers accurate, more comprehensive information about the patient’s health to enhance the ability to provide quick and efficient care, to better coordinate patient care, and to provide a way to share this comprehensive set of information with both the patient and their families (Department of Health and Human Services, 2014). The purpose of this paper is to explore EHR’s in entirety including the EHR mandate, who started it, when it was started, and what the objectives and goals of the mandate are. The connection between EHR’s and The Affordable Care Act will also be explored. Each facility has their own implementation of the use of EHR’s;

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).

The Electronic Health Record (EHR) is a vital tool in accessing the important details of the patient, the basic identification such as full name and birthday, the baseline vital signs and the past medical history as well as the current medical or surgical information. The integration of the EHR according to “the Agency for healthcare Research and Quality (AHRQ) study highlighted the overall economic value” as well of having an EHR (McGonigle & Mastrian, 2015, p. 255). The American Nurses Association (ANA) emphasized its goal of nursing informatics, which is to “improve the health of populations, communities, families, and individuals by optimizing information management and communication” in delivering excellent patient care utilizing the

Being able to tell about the roots of where the Electronic Health Records come from the paper will now look at the benefits of the system. The Electronic Health Records areis defined as, “electronic version of a patientspatient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports The EHR automates access to information and has the potential to streamline the clinician 's workflow.” (CentresCentre’s for Medicare & Medicaid Services 2012) With the EHR’s there are a lot of mixed emotions towards it being beneficial or not useful however the good outweighs the bad in this case. The EHRs have taken care of the duty of physically transporting paper records from clinic, to hospital , to lab and also the chore of having to re write medical paper records every time of going into a new medical setting. Also for patients that need their clinicians to access their forms it can be now easily at hand for them as well, making it less of a hassle to looking up a patientspatient’s medical history.

Electronic Medical Records (EMRs) are used throughout the hospital where I work. An EMR has led to many improvements in having access to medical records, in a timely manner. When a patient registers in the Emergency Department, I can see how many visits they have had. I can see all records, including past medical problems, allergies, test results, and a list of current medications they have filled at a Pharmacy. This is very useful when the patient omits information. It only takes a few steps to input protocols. An EMR decreases the risk of losing information or having to wait on records from the Medical Records Department. Additionally, the EMR allows Physicians to easily compare lab values from different visits and track a trend. EMR’s have become a valuable tool in Healthcare.

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

In an era of rapidly expanding science and technology usage, the Electronic Health Records (EHR) tools are a variety of tools used to improve quality measurement for better patient care and support ongoing quality improvement efforts. Without such technology support, it is hard to achieve for the management of the pharmaceutical care of patients.

Health Information Technology, or HIT, is defined by the HHS Office of the National Coordinator of Health IT (ONC) as, “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making”(HRSA.gov). HIT has improved healthcare in several ways, and continues to improve as well. HIT is used by many healthcare professions such as dentists, physicians, pharmacists, patients etc. (HRSA.gov). An electronic health record system (EHR), benefits both patients and healthcare professionals. EMR allows medical information to be more portable from provider to provider and from provider to health plans; it also enables patients to be more proactive in their own health. However, there are challenges with the implementation of this system, which can impede proper patient care. Wide variations in the levels of technological expertise, and a wide variety of responsibilities within the healthcare organization, does not help EHR education to be simply streamlined into one area of training and understanding, which allows for room for improvement when it comes to integrating a new system designed to increase patient satisfaction and decrease medical errors.