Concept Analysis On Electronic Health Records

As an organization that pride itself on continuous improvement it is time to move away from an electronic medical record (EMR) to an electronic health record (EHR). The organization currently utilizes three different EMR, each for different reasons. This has and will continue to make accessing patient information difficult and inefficient as access to each database is dependent on individuals role within the organization. Overall, this will continue to influence patient care negatively. Currently, only nurses have the ability to enter and change orders, therefore, all orders must be given verbally to the nurse or be written down. Further, the system only contains information of each clinics patients and not across the

The use of electronic health records (EHR) aims at improving the quality and safety of patient care. An electronic health record (EHR) is an electronic version of the patient’s entire medical history including past diagnoses, treatments, and current medications being taken. There has been a rise in the conversion to EHR from paper records because these electronic records can track patient data over time and monitor parameters such as trends in vital signs over time or vaccination history, all which contribute to the improvement in the quality of patient care being delivered (Department of Health and Human Services, 2014). EHR’s are used currently to make more efficient, comprehensive decisions about patients, because there is more information available at the fingertips of the providers. By adopting EHR’s, it can provide health care providers accurate, more comprehensive information about the patient’s health to enhance the ability to provide quick and efficient care, to better coordinate patient care, and to provide a way to share this comprehensive set of information with both the patient and their families (Department of Health and Human Services, 2014). The purpose of this paper is to explore EHR’s in entirety including the EHR mandate, who started it, when it was started, and what the objectives and goals of the mandate are. The connection between EHR’s and The Affordable Care Act will also be explored. Each facility has their own implementation of the use of EHR’s;

The electronic medical record (EMR) is the replacement of paper manual charts and is being used all across the country. As per Hebda and Czar (2013), the EMR is the “building block” of the electronic health record (EHR), which can be defined as “a longitudinal record that includes client data, demographics, clinician notes, medications, diagnostic findings, and other essential healthcare information” (p.293). The widespread use of EHR’s in America is foreseeable and inevitably unavoidable, but by no means a simple and undoubtedly an effortless task to achieve.

The study which has been outlined earlier, if conducted can either support or refute if nurses will need increased education and training on Electronic Health Records formerly known as EHR’s. If this study is conducted, nurses will know whether or not the education and training they are receiving traditionally on EHR’s is sufficient for gaining interpersonal relationships with their patients. Interpersonal relationships include patient rapport, effective nursing interventions, and patient safety. Nurses will know whether or not time is being sufficiently spent with the patient or if it is being occupied with EHR input because of lack of education, understanding and training.

Technology is changing how people communicate, work and establish relationships at the point that does not matter who you are, technology will be use in a certain manner. Healthcare is one of the industries that is being pushed to move forward and change their communication process and make patients information available 24/7. For many years hospitals, doctors, and another medical facilities were acting independently on the matter of administrate their own patient medical records, EMRs. Now they are required to convert those EMRs in electronic health records, EHRs. The difference between EMRs and EHRs are resumed in that EMRs contains the medical and treatment history of the patients in one practice only, and EHRs are designed to share information in more than one practice (Garret, 2011). EHRs are more global and will change the way we communicate in the healthcare industry.

Healthcare organizations (HCOs) are implementing patient portals and beginning to allow the patient access to pieces of their record online through web portals. This is a step toward actually implementing an electronic health record (EHR). According to Garets and Davis (2006), an EHR is actually a subset of an electronic medical record (EMR) and is actually an interactive piece that allows the patient to add and correct data in their personal EHR over time. Data is shared with the regional health information organization (RHIO) or the national health information network (NHIN) via summary documents like the continuity of care record (CCR) or continuity of care document (CCD). In order for the patient to have the ability to share this data

The electronic healthcare record system is a new form of technology that help nurses and doctors with their jobs every day. Electronic healthcare records, or EHRs, are a digital record of patient’s medical history from many different hospitals or clinics (Huston, 2013). Arizona College (2015) claims that “ by 2013, eighty percent of hospitals have implemented the use of EHRs for accessing, processing, and storing patient information”. People rely on these medical records to be at every hospital or clinic they go to and the EHRs make it possible. “The EHR is available 24 hours a day 7 days a week and has a built in safeguard to assure patient health information confidentiality and security” (Huston, 2013). This 24 hour access allows all nurses

The United States is entering a new generation of healthcare, requiring providers to use electronic health records to improve the new technology that have grow to a better use. The electronic health care replace all kind of information of medical records writing down on paper. Back in 2003 the (IOM) Institute of medicine create the use of EHR and stablish the eight core functions requirements to improve some issues. The quality care, feasibility, chronic disease management, and efficiency was needed to change for patients care.

“By 2015, use of a certified electronic health record (EHR) is mandated under the Health Information Technology for Economic and Clinical Health (HITECH) Act” (Kelly & Tazbir, 2014, p. 129).Electronic health records comes from the electronic medical records data and where nurses document the patient’s care that has the ability to move from one provider to another. “The main purpose of documentation is facilitating information flow that supports safety, quality, and continuity of care” (Kelly & Tazbir, 2014, p. 131). Electronic health records also improves the quality of confidential health information as compared to the paper system. Informatics is defined as “the use of information technology as a communication and information-gathering tool

A clinical information system (CIS) collects patient information from technological applications. The information is distributed to certain locations in the facility/healthcare setting. Locations vary based on unit, such as OBGYN, cardiology, ICU, or psychiatric. The CIS represents the patient’s history of illnesses and interactions with health care providers by encoding knowledge capable of helping clinicians decide about the patient’s condition, treatment options, and wellness activities (Sittig et al., 2002).

The health care system has come a long way from pen and paper. An introduction of computers slowly started to change the way doctors and nurse would chart. From paper charts and filing to scanning into the computer and keeping files on a floppy dicks and CDs. Now we are able to utilize an electronic computer charting system and a development of electronic health records. EHR is now a standard of handling information as well as storage and sharing of patient medical information that many people use and some people abuse.

EHR has enormous effect on the modernization of the healthcare field. It is a continuing electronic record of patient medical information created by one or more persons in any healthcare delivery system (Huston, 2013). Encompassed in this data are patient’s vital signs, statistics, and health issues, also include progress notes, past surgical or medical record, treatments, vaccinations record, radiology reports, and laboratory tests result (Eisenberg et al., 2013). The EHR has the

An Electronic Health Record (EHR) is a system that collects and tracks health related information of an individual and populations in a digital format (1). It provides key clinical data associated with the individual including: demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports (2). The purpose of the EHR is to allow health care providers real time access to a patient’s records to provide the patient with the best care possible.

Nurses’ documentation in the patient record has different purposes-from ensuring accountability and justification for patients’ interventions provided to ensuring quality, continuity and security for patients through a trajectory of illness (Gjevjon & Hellesø, 2010). When this process is done using health information systems (i.e. EMAR or EHR), it is called electronic documentation (eDoc.). According to Abiri (2014), eDoc help with mitigating medical errors and improving patient safety which are indices of quality patient care.

There are several roles related with patient health records. Not merely is the record employed to record patient care, but it is in addition utilized in recording and tracking financial and legal information, and research and quality development reasons (Brenda et al 2008). The fact that all this information is shared by thousands of health professionals, insurance companies and certain public health agencies calls for the development of an automated electronic medical record system that will provide healthcare professional and other relevant professionals easy digitalized access to the patient information (Ethier 2003).