Application For Successful Electronic Health Records

The Role of Electronic Health Records and Health Information Exchange in the Delivery of Quality Healthcare

Electronic health records are helpful to physicians and healthcare providers, because they can be used between different health facilities and agencies. The Electronic Health Record system can be used to improve the effectiveness, quality care, and reduce cost in the future. This record of information contains the history of the patient’s visits to a healthcare facility along with all documentation regarding contact information, patient histories and allergies. The record also contains a list of medications, billing information, and data pertaining to the patient’s visit. The computerized physician order entry (CPOE) allows the physician to electronically enter patient’s orders and view a patient’s lab or x-ray results. It can help detect adverse effects or medical errors and reduce less suffering of the patient if he/she were to receive the wrong medications.

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.

The federal government established a nationwide health information technology (HIT) infrastructure which requires all health care facility personnel to use an electronic health record (EHR). According to Sewell & Thede, in 2004, President Bush called for adoption of interoperable electronic health records for most Americans by 2014. Electronic health records (EHR) is an automated system created by healthcare providers or organizations, such as a hospital in documenting patient care. In addition, EHR is an interoperable healthcare record that can comprise of multiple EMRs data and the personal health record (PHR). Furthermore, electronic health records can be created, managed, and accessed by approved clinicians and staff across more than one health care society (Sewell & Thede, 2013, p. 231-232). On the patients’ perspective, EHR will be used to support healthcare by providing electronic record of patients’ vital signs, demographics, allergies, medications, diagnoses, and smoking status. Consequently, on the providers’ perspective, EHR will support healthcare by use of decision support tools, enter clinical orders, such as prescriptions, provide patients with electronic versions of their health information, use systems that protect the privacy and security of HER patient data. Another meaningful use of EHR is to support activities such as conducting drug formulary checks, including clinical laboratory test results, recording advance directions for patient 65 years and

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.

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.

The electronic health record is the electronic version of a patients’ medical chart (Centers for Medicare & Medicaid Services, 2012). The information included in the electronic health record is the patient’s demographics and clinical health information, medical history, list of health problems, progress notes, medications, vital signs, laboratory and radiology reports, and physician orders. The purpose of the electronic health record is to prevent medical errors and improve care delivery to provide a safer patient environment (McGonigle & Mastrian, 2015).

My interest in all things healthcare related led me to take a position as an electronic health records (EHR) specialist and trainer at North East Medical Services, a federally qualified health center based out of San Francisco. With no prior computer programming background, I accepted the challenge and fed my curiosity by entering unfamiliar territory. Through this experience, I gained a unique perspective on the physiology of a health clinic from medical coding to charting and was privileged to witness the transformative work of a nurse practitioner. The role refined my abilities to lead execution intensive projects with time constraints and to stay present and grounded in high-pressure situations.

“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” (CMS, 2011). Paper charting can no longer support the needs of our healthcare industry, and EHR is replacing it throughout healthcare settings in a rapid way. Also, once the patient is discharged from the healthcare setting, paper charts are stored in medical records and a new chard would open if the patient comes back later, allowing key information to be missed and put the patient safety in jeopardy.

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.

I understand your concerns regarding the legality of the electronic signature. Electronic health record system have many policies and rules that must be followed in both state government and federal. In 2000 the U.S. Government passed a law that gave electronic signature the same legality as written signature. It doesn’t mean that its signed electronically that anyone can access it and sign it for you. Your signature authentication requires a password, biometric, and unique code this identifies that its you who is the signer in the system. If someone tries to access any documents to sigh them they will not be allowed because the system will not recognize it if it wasn’t you. To be save there are passwords that go along.

As an Electronic Health Record worker it can be difficult with patients medical history, diagnoses, medication, treatment plans, immunization records, and radiology; a lot of this can be overwhelming because you have to make sure when your doing these things it takes times rushing into it may cause errors and huge mistakes when dealing with a patients health and there life itself. Things that you do can reflect on improving their quality of a patients care. For one not having enough training can be an issue maybe to much information to capture at one time.Lack of interoperability between information technologies, cost of set-up and maintenance, HIPAA violations, empty data fields, coping and pasting and end closing. It would definitely be best

Electronic health records (EHRs) are a mainstay of HIT, and, since the passage of the HITECH Act in 2009, almost all hospitals and most physician practices have adopted some sort of EHR. Benefits of EHRs fall into 3 major categories: 1) quality, outcomes, and safety, 2) efficiency, productivity, and cost reduction, and 3) service and satisfaction. Many challenges to adoption and usage of EHRs exist. High cost associated with the adoption and maintenance of EHRs can be a limiting factor to their adoption. Technical issues, such as lack of controlled terminology can affect the capturing of clinical data. Another technical barrier is user familiarity with computers. Older users are more likely to resist incorporation of computers into their workflow

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.

As the healthcare landscape continues to shift and evolve, public health departments find themselves facing numerous complex challenges. This makes it imperative that local health departments and individual providers work together to improve the health of their communities.