Clinical And Patient Portal: Case Study

The use of technology in HIM department works out well and effectively. Each patient who is new is assigned a unique medical record number and it always remains the same for the patient each time he/she want to get health care from this health care system. Another system

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

Modern communications capabilities open up a world of possibilities for all types of medical practices to develop deeper connections with their patients and to manage health care remotely. The HIPAA Privacy Rule gives patients the right to obtain copies of their medical records, treatments and protected health information or PHI. These requirements go further if medical providers want to receive reimbursement from Medicare and Medicaid -- patients must be able to access their records online, download copies and transmit the information to third-party providers. Most medical practices are finding it necessary to develop patient portals where patients and physicians can interact, share information and perform important functions such as practices billing patients and accepting payments online. HIPAA 's rules require that these patient portals have strong security and privacy protections to prevent unauthorized access of these confidential PHI records.

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.

Healthcare reform has created incentives to increase patient engagement to increase accountability, healthcare outcome and lower healthcare cost. In the early days of this movement, web portals were created with basic functions of requesting appointments, prescription refills, and paying medical bills (Butterfield, 2013). Today, patient portals allow users to access dictated visit reports, labs, approve access controls combined with the function of the web portals. As more health information is pushed to the portals, the users (patients and family) are more involved with healthcare decisions and more knowledgeable on available options that meet individual need.

Communication is the key in a health care field and having patient portals has increased information sharing between physician, nurses and patients. Patient portal is software that allows patients to get access to their own electronic medical record in a secure, efficient and easy to use program. Patient portals offer updated list of medications, diagnosis, allergies, lab results, patient history and more. Patients have access to their portals, which allows them to keep themselves up to date on not only their history but new information that doctors and nurses have given them. Also, having access to their portal allows them to keep updated information such as, discharge instructions for better care. This eliminates the time the nurses would spend on phone tag. It is a secure online software that provides patients with privacy and own username and password.

Six long, strenuous months have passed since the last doctor’s appointment and the pain increases rapidly. Busy schedules prevent many individuals from scheduling a second appointment, and when this occurs people seek comfort through the internet. Medical websites provide copious amounts of information on diseases, symptoms, and alternative methods of treatment but they are not a cure for diagnosis. These websites produce harmful effects on the mental health of patients, and they should resist the urge to google a treatment plan before the doctor diagnoses one. The equipment and resources available at clinics and hospitals provide more accuracy than the internet ever will.

So, you’re probably wondering “Is WebMD reliable or not?” (Gutierrez, 2017). According to WebMD’s editing policies: “The sponsor is responsible for the accuracy and objectivity of their content and the content is not reviewed by the WebMD Editorial Department for accuracy, objectivity, or balance” (WebMD, 2017). So, whether WebMD is a scholarly resource or not, in my opinion it can go both ways.

The American Health Information Management Association (AHIMA) website was very detailed and laid out. It was also very user friendly when it came to learning or finding information on health information technology. The AHIMA is the most leading association of health information management (HIM) specialists globally. The AHIMA has played a major role in leadership and in finding efficient ways for management of health data and medical records that are required to distribute quality healthcare to the patients. Furthermore, AHIMA is supporters for the HIM profession, aids as a “thought leader” in the global world of HIM. Also, AHIMA is “one of the four cooperating parties responsible for the ICD-10 Coding

Technology has had a role in healthcare for some time, but only recently has it matured to a point where it can support operational, business and clinical functions of healthcare organizations. In the past, many hospitals used technology for specialized departments and unique roles, but the concept of a complete electronic health record system did not exist until the early 2000’s. The American Hospital Association (AHA) Information Technology (IT) Supplement to the AHA Annual Survey stated that in 2008 only 9.4% of hospitals had a basic electronic health record (EHR) system (HealthIT EHR, 2014). They defined a basic EHR as having electronic clinical information that includes results and the ability to enter and view clinical notes. Without the ability for healthcare organizations to capture clinical information electronically, an online patient engagement solution cannot

I learned a lot while researching for my topic electronic clinical documentation. As a nurse who has seen many changes in the medical world we live in , I braced myself for the challenges that came when I was informed our clinic would be going live with Epic in 1 year . It seemed like an eternity of classes but the extensive training and time to play in the learning playground of Epic , left me , the providers and the staff prepared for the challenge . Don’t get me wrong, we had some very frustrating days and some very extended hours but the positive aspects of the electronic medical record (EHR) soon out weighted the negative .The long extended hours documenting what we did in the first 3-4 months

Compassion, Dedication, Responsibility, Empathy these are just some of the many things nurses should have when caring for a patient. I have had the opportunity to provide service at St. Elizabeth’s hospital. I worked with St. Elizabeth Hospital Patient Portal Program; I would go from room to room and ask each patient if he/she would like to set up their patient portal where they have the option to see their test results and all their medical history on an online database. Many thought this was an excellent idea. You would enter a patients room and see that their not in the best condition. Going in a patient’s room can be scary at times however, going into a situation confident that you maybe unsure about is the best thing you can do. After

There are some assumptions made by university health care system in its implementation that the common advantages of using a computerized system would obviously work to their own advantage. Users of the system make a great impact to the existence of the same. It is imperative to consider old data that is supposed to be fed to the system in order to make it efficient while updating the rest of information. Self evaluation process is recommendable to the system by the Information Technology experts. The human interface of the system should be included by the evaluation team. This will include two psychologists. The above aspects should be considered by a team of analysts before they conclude on whether the project does or does not

Health Informatics created two main categories such as clinical and administrative information systems to meet the needs of one or more department within the health care organization. For the clinical information system, it is set to meet the needs in improving patient care. Therefore, the clinical information system (CIS) categories provide nurses information systems (NIS) that support the way nurses documents the care that given to the patients. However, to improve the delivery of nursing care, the healthcare organization must adopt a computer system that can successfully incorporate tools that will benefit nursing. There is two vendors’ software that implies these characteristics for the

In order for one to understand the risks involved in the use of electronic medical records one needs to understand the meaning behind what it is. An electronic medical record (EMR) is a