Electronic Case Report Form ( Ecrf )

One of the issues with the electronic systems in health care for MU is the ability to retrieve laboratory results during a patient’s visit. In 2013, Hinrichs and Zarcone reveal that over 70% of medical decisions are determined by laboratory results. In 2007, AU Health implemented Cerner Millennium PowerChart that displays clinical data to improve the point of care for patients. With the PowerChart solution, the patient’s information can be easily verified, vital signs can be entered, and family history can be updated. The Affordable Care Act (ACA) signed by President Obama in 2013 places emphasis on expanding insurance coverage of medical care for everyone. As part of the ACA, the improvements in the way these results are exchanged and transmitted will add value to quality, safety, efficiency of health information (Hinrichs & Zarcone, 2013). The transmission and availability of EHR affect how other health professionals send and receive information at the local, state, and national levels.

The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies. The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. (Huston, 2013)

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

The purpose of this discussion board is to describe the Electronic Health Record (EHR), the six steps of an EHR and how my facility implements them, describe “meaningful use” and how my facility status is in obtaining it, and to further discuss the EHR’s and patient confidentiality.

Health care agencies invest large sums of capital into EMR and in addition, rely upon reimbursement from the Health IT system (for example Medicare and Medicaid). According to Hurdle et al., (2007), the American Medical Informatics Association [AMIA] Code of Ethics, “patients have the right to know about the existence of electronic records containing personal biomedical data” (p. 391). In addition a patient has the right to expect that “biomedical data are maintained in a safe, reliable, secure, and confidential environment that is consistent with applicable law, local policies, and accepted informatics processing standards” (p. 392).

Electronic health records were a technological advancement in the healthcare industry in which paper patient record’s became digital. The transition from paper to digital charting allowed easier, quicker access to patient information for those who were authorized to do so. EHRs are secure and protected with username and password access only. It contains information such as patient medical history, procedures, diagnoses, medications, labs, tests, and treatments. Healthcare professionals and organizations who are authorized to access a patient’s electronic health record can do so at ease via a secure network or online database (HealthIT, 2013).

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

EHRs have potential in recuperating patient safety. EHRs are efficient as they do not require doctors to use paper records, which in turn result in healthier individuals (Staggers, Weir and Phansalkar, 2008). Furthermore, Canada and many other countries around the globe have invested in EHRs due to the advantages for patient safety. Moreover, EHRs have its advantages, but there are also evident disadvantages, such as financial costs, patient safety, and medical errors (Sparnon and Marella,

By making health information accessible across an entire Acute Care System, Cerner EHR facilitates improved safety, care and coordination by providing clinicians with real-time health information, so that they are able to make more accurately informed decisions. Their electronic health records system eliminates the need for hand-written documentation, provides medical records clarity, improves accuracy and reduces errors. Cerner’s customizable applications were specifically designed to streamline both administrative and clinical tasks. These automated processes, ensures health care professionals are better equipped to maintain and perform all key administrative manipulations of clinical data relevant to each patient of record. Cerner EHR also

Although the general population has concerns about who has the ability to access their medical records, data has been put into place showed that the general population knows that having an EHR would be beneficial (Thede, 2010). Research has suggested that patients, providers and insurance companies have benefited from EHRs because insurance companies do not have to pay for duplicate testing as well as patients and providers having the ability to increase the quality of care that is provider (Thede, 2010). Not to mention, the patients aren’t pained to have to remember every detail of the history when visiting various specialist (Thede, 2010). Moreover, EHR can increase medical staff efficiency and reduce errors, and keeping adverse drug events from happening (Bill to promote electronic health records proposed, 2008).

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 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

“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an

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.

Electronic medical records had a great impact in the ushering in of the age of Nursing Informatics. (Himss, 2010)EMRS present healthcare professionals with the ability to retrieve and organize data in a quick and efficient approach. With information so readily available, patient safety increases and we know that patient cost goes down. This happens because patient medications, allergies, history, demographic, and treatment information is more collectively available.