A Brief Note On The Electronic Health Records Essay

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.

Over the past few years, we have notice a significant change in the workflow of a healthcare organization. This change is caused by the technological advancements of Health Information Technology (HIT). One of the many technological advancements of HIT is the Electronic Health Record (EHR). Electronic health records are a patient’s paper chart in a digital format. It always contains real time information and can be easily accessible. With EHR put into act, it has the ability to electronically view and share a patient’s medical history, past and current medications, immunization dates, any diagnoses or allergies, as well as testing and lab reports. It is also used to document and store data, in addition with many more abilities. It is important to understand the purpose, application, challenges, and advantages of an electronic heath record. In order to get a greater understanding of its use, we will use a private family medicine practice as the foundation for implementing the EHR.

The advancement in technology has rapidly transformed the world today, and the increase in the number of web-enabled devices has completely changed peoples ' lives especially the way they communicate. Electronic Health Record system, which is a digital copy of a patient’s medical history is one of the revolutionary ideas that have come with this advancement. Electronic Health Records (EHRs) are instantaneously updating records that are patient-centered designed with the aim of providing real-time information to the authorized users (Cohen, 2010). It contains all the patient’s information that is in the hand of the medical providers including their medical history, treatment dates and types, immunizations conducted to the patient and their dates, radiology images and all the laboratory results from the tests conducted in the past. All this information is held in a digital format and can only be updated by authorized users who are stationed in the medical facilities. Electronic records are designed to make it easy for different health providers and organizations to share patients’ information which streamlines their operations since all the necessary information and history can be accessed from any location at any time.

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

There’s no denying that EHR has advanced the quality of healthcare by improving the way information is accessed and exchanged. But despite these advancements, errors, which were simply not tolerated in paper records, are numerous in EHRs. Because of this, electronic documentation tools have been developed in an effort to increase the quality of clinical documentation, enhance communication between healthcare providers, and improve delivery of care.

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

The purpose of this paper is to discuss the Electronic Health Record (HER) mandate, including its goals and objectives. It will further address how the Affordable Care Act and the Obama Administration connect with the mandate. The plan my facility used to meet the goals of the mandate, as well as what meaningful use is and our status of attaining it will be discussed. In addition, HIPAA laws, the dangers to patient confidentiality, and what my facility has done to prevent these will be presented.

Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.

Collaboration and communication between patient’s, their physicians and the health care team are required in order to preserve the safety of the patient. Improper use of EHR can produce errors that may possibly threaten the reliability of the information in the EHR which may endanger patient’s safety thus decreasing the quality of care. Healthcare quality relies on the accuracy and integrity of the patient’s health information. One manner EHR accuracy may be-threatened is because of the growth of members of the healthcare team copying and pasting text documentation. The copy and paste process poses a risk to the integrity of nursing documentation. Risk such as, redundant documentation, outdated documentation, and inability to identify when

When the electronic health record is coded, it can be utilized for trending, alerts (warnings or signs), health maintenance, and decision support. It can be recognized correctly and electronically distinguished by way of the computer. Document image data must have an individual to look at and understand the information. Also, codes remove uncertainties about the physician’s meaning and diagnosis. It’s very crucial and essential to document a code acknowledging the clinical data as well as to the explanation of the text. A documentation is referred to as codified when the code is saved in the patient’s electronic health record. A codified electronic health record is more beneficial because it classifies the medical provider’s results or treatments.

Over the past decade, virtually every major industry invested heavily in computerization. Relative to a decade ago, today more Americans buy airline tickets and check in to flights online, purchase goods on the Web, and even earn degrees online in such disciplines as nursing,1 law,2 and business,3 among others. Yet, despite these advances in our society, the majority of patients are given handwritten medication prescriptions, and very few patients are able to email their physician4 or even schedule an appointment to see a provider without speaking to a live receptionist. Electronic health record (EHR) systems have the potential to transform the health care system from a mostly paper-based industry to one that utilizes clinical

With the use of technology at its glance, the use of Informatics in health care systems is improving and benefiting patients, family and the community. Informatics improve research, communication, documentation, diagnosis, education, and preventing of errors in the health care system. The use of paper charting increase errors, loss of documents, which could interrupt patient treatment and safety. Informatics is also useful in keeping patient medical records, track patient treatment, and progress.

Electronic Medical Records or Computerized Medical Record System what is it and what are the advantages along with the disadvantages of using this system? That is what we will discuss in this paper.

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

Electronic Medical Records (EMRs) are now exercising a more significant impact on healthcare practices than ever before. The United States healthcare system stands on the brink of a new age of electronic health information technology. The potential for innovation within this new technology represents a great opportunity for the future of medicine. However, in seeking to implement EMRs caution must be exercised to ensure that implementation does not have adverse effects on the personal nature of the patient-physician relationship an important issue that must be addressed in order preserve the integrity of healthcare in the new electronic age.