The Electronic Health Record And Clinical Decision Support

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 the modern world technology is everywhere and it affects everyone’s daily life. People are constantly attached to cell phones, laptops, and other electronics, which all have affected how people live their lives. Technology is also a large part of the healthcare system today. There are many electronics and technologies that are used in health care, such as electronic health record, medication bar code scanning, electronic documentation, telenursing, and there are many more forms of technology that impact nursing. One technology that stands out is the electronic health record. The electronic health record, also referred to as EHR, is an electronic version of a patient’s chart, and it contains is a list of the patient’s current medications, allergies, laboratory results, diagnoses, immunization dates, images, treatments, and medical history (“Learn EHR Basics,” 2014). The purpose of the electronic health record is to have a patient’s health care record available to health care providers nationwide, but the patient can decide who has access to their record (Edwards, Chiweda, Oyinka, McKay, & Wiles, 2011). The electronic health record is a very important technology in health care and it impacts nurses, nursing care, and has a significant impact on patient outcomes.

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.

In Stage 3, enhancements to the UMUC Family Clinic business process will be proposed by recommending HIT (health information technology) solution, consisting of a certified EHR (electronic health system)/EMR (electronic medical records) system. Once this system is implemented, it will immediately improve the current process. Customer complaints are high, and the focus is on the long wait times and redundant processes when a patient arrives to be checked in. Moreover, some nurses are not readily available, because they are preoccupied with other administrative duties within the practice. Inconsistent record keeping practices lead to additional time searching for patient records. A HIPPA violation may be detected if a patient’s record is misfiled or lost; henceforth, creating a need for supplemental time and possible duplication of another medical record may be required. This process can be greatly improved by the HIT solution using a terminal loaded with the EHR solution. This will allow patients the ability to enter all of their health record information upon their arrival and that information will be instantly available to the nurses and doctors. This process will also give the patient the opportunity to validate the information and make any necessary changes (benefit information, addresses, phone numbers, and medications).

The success of the implementation of the electronic health record was based on employee attitude, listening to concerns and feedback, including bedside nurses in the workflow analysis and vendor selection, collaborations with other organizations utilizing the same electronic health record, staffing well during the initial implementation, and adequate training of staff (Maust, 2012). The challenges encountered were due to some negative employee attitude, not enough education for nursing staff, policies and procedures that do not reflect the new electronic health record, and lack of education for patients (Maust, 2012). The conclusion of this article emphasized the importance of investing in training nursing staff and the role of nurse educators in providing adequate information prior to implementing a new electronic health record (Maust,

Focusing on the outcome and not the process of the outcome, a needs assessment is a systematic approach to the electronic record adoption project scenario. The outcome of a needs assessment given scenario is the adoption of an Electronic Health Record system by the health care organization. For the site to adopt and accept implementation of an electronic health record system, benefits have to be clearly outlined and presented to the site staff. The staff must be convinced that the core functions of implementation of an electronic health records system is management of patient health information and data. Transitioning from an analogous patient records too EHR system, patient information and knowledge becomes immediately accessible and navigable by medical personnel. Electronic Health Record system would also provide the staff immediate access to testing result and CPOEs. Electronic health record CPOEs eliminates the self-evident sometimes ineligible physician order. Eliminating the time from when the physician prescribes the order to the time the procedure is performed is a core benefit to electronic health record application. Finally the staff needs to be informed that one of the outcomes of an electronic health record application system is decision support. Prevention, drug prescription, diagnosis, and disease management are functional EHR decision support functionality applications (“Comprehensive Needs Assessment,” ed.gov, 2001).

Electronic Health Record played a major impact in biomedical decision making. It is designed to be used as part of the consultation process. Data cannot be utilized in health care unless they are recorded can facilitate the chart review process. Biomedical used computer data retrieval and analysis techniques to do most of the work. They used HER to monitor the content and generate warnings or advice for the biomedical provider based on a single observation. EHR helps to improve patient safety, legibility of clinical’ preventive services are overdue and reminds clinicians about patient allergies, the correct dosage of drugs. EHR provide problem summary lists of diagnoses, allergies, and surgeries at one glance. Electronic record help in providing

An effective Electronic Medical Record (EMR) is more than a management tool for controlling patient data. Methods used to monitor implementation, relationship between organization’s processes, professional roles, and communications techniques used to address issues during implementation are points to develop in this paper. The essential capability of this system consists in capture data at the point of care, integrate this information from the internal or external source, and support caregiver’s decision-making (OpenClinical, 2010).

Electronic health records are increasingly being implemented in many countries. For the longest time, Canada has always needed an easily accessible, speedy, efficient, and cost-effective method to access information. Electronic health records, also known as EHRs, have been introduced to be a secure and private lifetime method to that record and provide a person’s health history (Saher, CA et al., 2010). It is known to be a new division of health care, in which paper documents have been transformed into easily accessible digital documents. These types of records are made up information from many sources, which include doctors, pharmacies, hospitals, clinics, etc. (Saher, CA et al., 2010). Information from these records are considered to be important, as it helps for future treatments, and it can be easily accessed by health care providers (Saher, CA et al., 2010). EHRs aims to be much easier and quicker compared to old-fashion paper. The main purpose of an electronic health records is to improve the health care system, such as being organized and up to date manner, as well as sharing information between health care groups without any problems to occur. Although the benefits seem to be reasonable enough to be considered a replacement, however, there are many barriers to be considered when using EHRs as a replacement from paper documents. This means that this new concept can also lead to challenges, such as privacy issue, the impact on the environment, changes in

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

The purpose of the report is to discuss and decide on what EHR system would be best suited for the overall office staff, from the physician to the medical assistant, in entering pertinent information in the patient’s electronic chart. The data that needs to be collected, sorted and retrieved fall into three categories: Personal patient information, administrative and billing data, and patient demographics. Office visit medical data, Progress notes, Vital signs, Medical histories, Diagnoses, Medications, Immunization dates, and Allergies. Data from diagnostic tests, medical lab results and medical test results as well. (“What information does an electronic health record (EHR) contain? ” 2013)

Electronic health record systems are very helpful in the outpatient setting, but EHRs are only as good as the staff and the staff that input data into the system. Electronic Health Record systems have many functional applications in the outpatient setting. Task lists, communication with others within the practice, and improving billing accuracy and claims, are just three of the many functional applications EHRs provide to clinical end-users in an outpatient setting. By creating day to task and imputing those tasks into the electronic health care system, a day to day pace is set for the individual and other members of staff. Communication with others in the practice is improved through electronic health record systems. An atmosphere of more

An electronic health record (EHR) is a computer-based data warehouse of information regarding the health status of a client. It is the systematic documentation of a client’s health status and health care in a secured digital format. This form of electronic charting will replace the former paper based medical records. It is estimated that only about 2% of hospitals have a fully deployed EHR (Baker, 2012). The Institute of Medicine (IOM) has outlined eight components of an EHR that place emphasis on functions that promote patient safety. The eight components include (1) health information and data, (2) results management, (3) order entry management, (4) decision support, (5) electronic communication and connectivity, (6) patient support, (7) administrative processes, and (8) reporting (McGonigle&Mastrian 2012).

In previous years, the health industry relied on a paper-based system to organize, store, interpret, and integrate patient records and medical information. However, with the informatics industry booming and allowing for new electronic technology and information systems, clinicians now find this data stored in convenient coded computer systems. According to AHIMA, Health information is the data related to a person’s medical history, including symptoms, diagnoses, procedures, and outcomes. Health information records include patient histories, lab results, x-rays,

In today’s medical field technology plays a big role when it comes to patient care. Technology is huge when it comes to giving the patient the best type of quality care when they are in the hospital. In the old days people would just write it down on a sheet of paper and record it by hand, which caused mistakes. Now with the Electronic Health Record those mistakes are drastically declining. Statistics have shown that using the Electronic Health Record has lowered Nursing mistakes as well as improved patient care. Our society has progressed through the years and has been introduced with the Electronic Health Record which has drastically improved our health care system. The Electronic Health Record provides great communication between