Essay On Ailment Registries

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

In today’s society, the accuracy of health information, the availability of health records, and the professional resources in which one live are vital in decision making for health conditions. Meaningful Use (MU) is a program developed by CMS Medicare and Medicaid that awards, incentives in the health care industry in which the certified electronic health records (EHRs) are used to improve patient care (Practice Fusion, 2016). These incentives are for professionals that care for about 30% of their adult patient volume or 20% of their children’s volume for Medicare and Medicaid patients (CMS, 2016). In addition, adjusting from paper charts to electronic charts of patient’s information is beneficial for MU. Furthermore, the American

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.

According to Chtourou (2013), a CDI program focuses on enhancing the accuracy of clinical documentation quality which requires a huge input from CDI specialists, heath information management professionals, coders and clinicians to collaborate together to review the quality of documentation reported/captured in order to ensure accuracy and complete of patient’s clinical encounter. As a healthcare provider, medical records that are incomplete or inaccurate often times, compromise the quality of care reporting and inevitably affect the clinical decision support system of the organization including the accuracy of reimbursement. This is reasonable since the CDI program has emerged as a new paradigm to meet the changing needs of maintaining a sound health record documentation across the healthcare industry (Hauger, 2014). Most of the CDI programs have to a great extent concentrated on boosting the Diagnosis-Related Groups (DRGs) installments by securing clinical documentation to support medical complications and co-morbidities (Hauger, 2014).

Our one hundred bed hospital is in need of updating from paper charting to computerized health records. In doing this, we will meet our goal of compliance with meaningful use legislation. We assembled a team of members to assist with this task and together we have narrowed the search to two health care systems. Those two systems are EPIC and Meditech and we will now discuss the advantages and disadvantages of each, with a final recommendation for our new healthcare system.

“a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.”(Santiago, n.d., para. 1)

According to Rosenbaum et al. (2015), healthcare documentation combined with clinical communication that is coded for hospitalized patients is an important part of medical care. The paper or electronic healthcare record is then submitted to third party payers that provide reimbursement for services based on the guidelines of the Centers for Medicare and Medicaid Services (CMS), Medicare Severity Diagnosis Related Group (MS-DRG), and inpatient prospective payment system (IPPS) (Rosenbaum et al., 2015). The

Electronic Health Record (EHR) is an electronic version of a patients 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 (Ehlke & Morone, 2013). The incentives from both of this articles will result in the delivery of quality care to many individuals in

But as noted previously, more is needed than standardizing these processes. Health care providers (physicians and hospitals) should embrace electronic health records (EHRs) and should integrate appropriate information from billing systems with clinical information (the recording and analysis of clinical services) from EHRs (Wikler et al., 2012; Cutler et al., 2012). To address concerns that occur due to accessing medical records, the secretary of health and human services could expand criteria under the Health information Technology for Economic and Clinical

In order to meet the requirements set forth by the Federal Government many health care institutions began the painstaking process of seeking out an electronic program. These institutions sought to purchase a system that would have the capacity to interact with other programs, and the flexibility to allow all clinical personnel easy access to pertinent medical information such as labs, diagnostic test results and past medical history.

There are many types of data collected, such as, Demographic, financial, socioeconomic, and clinical data are collected from patients so that the healthcare providers of services to the patient are able to assess the history of whatever disease the patients is suffering from and how is to be treated. Data collection in the facility is well organized in a way that promotes shared assessment, treatment and communication. Nurses and front row staffs collects raw data’s from the patient, and. The Heath Information Manager and team are the facility are responsible in analyzing and presenting the data collected in a meaning and easily understandable way to served the specific purposes for which it was collected. Examples of such data are, patient’s name, height, weight, gender, allergies, and third party

The healthcare industry is in the midst of a major change from paper based medical record keeping to electronic medical record keeping. As part of the American Recovery and Investment Act of 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed (Office of the National Coordinator for Health Information Technology, 2014). HITECH is the U.S. Government’s first major contribution to the change from paper to electronic health information technology by setting meaningful use incentive program for Medicare and Medicaid providers that met certain requirements. Healthcare professionals that meet the meaningful use criteria will be awarded financially, and those that don’t meet the 2015 guideline will be penalized. We live in an electronic world of instant access to information and by adopting health information technology we give providers better and easier access to more information which in turn allows them to make a more informed diagnosis and treatment plan for the patient. The electronic health record (EHR) is part of the new information technology. According to the Office of the National Coordinator for Health Information Technology (2014.), EHR’s provide many benefits such as improvement in the quality of patient care; improvement in the coordination of patient care; more accurate diagnosis and better outcomes; a higher level of patient participation in their own care; and cost savings for the practice

Increased public demand to access health information and growth of consumerism in health care industry are two important reasons form increasing attention to Personal Health Records (PHRs) in the recent years. Surveys show that a considerable number of people want to have access to their health information. In one survey, 60 percent of respondents wanted physicians to provide online access to medical records and test results, and online appointment scheduling; 1 in 4 said they would pay more for the service.

The problem the industry faces today is the lack of utilizing available IT resources within the healthcare organization. “As per the 2008 statistics in the NEJM article Electronic Health Records in Ambulatory Care - A National Survey of Physicians, NEJM 359:50-60, just four percent of physicians in the U.S. reported having an extensive, fully functional electronic-records system, and just thirteen percent reported having a basic system.” (Scot, 2015) The major implication of the problem is quality of care. Healthcare IT can help an organization improve medical efficiency, reduce costs, improve research, provide earlier detection and more.

Once data is collected it can be used by numerous health care providers and decision makers to monitor the health and needs of individuals and populations, as well as contribute to the analysis of the health system. Users including hospitals, health care practitioners, government, professional associations, researchers, media, students, and the general public. Having the correct and up-to-date coded data is critical, not only for the delivery of high-quality clinical care, but also for continuing health care, maintaining health care at an optimum level, for clinical and health service research, and planning and management of