Electronic Clinical Documentation Of Healthcare

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.

Although the EHR is still in a transitional state, this major shift that electronic medical records are taking is bringing many concerns to the table. Two concerns at the top of the list are privacy and standardization issues. In 1996, U.S. Congress enacted a non-for-profit organization called Health Insurance Portability and Accountability Act (HIPAA). This law establishes national standards for privacy and security of health information. HIPAA deals with information standards, data integrity, confidentiality, accessing and handling your medical information. They also were designed to guarantee transferred information be protected from one facility to the next (Meridan, 2007). But even with the HIPAA privacy rules, they too have their shortcomings. HIPAA can’t fully safeguard the limitations of who’s accessible to your information. A short stay at your local

The purpose of this paper is to discuss the electronic health record mandate. Who started it and when? I will discuss the goals of the mandate. I will discussion will how the Affordable Care Act ties into the mandate of Electronic Health Record. It will describe my own facility’s EHR and what steps are been taken to implement it. I will describe the term “meaningful use,” and it will discuss possible threats to patient confidentiality and the what’s being done by my facility to prevent Health Information and Portability Accountability Act or HIPAA violations.

Several years ago, a mandate was ordered requiring all healthcare facilities to progress from paper charting and record keeping to electronic health record (EHR). This transition to electronic formatting has pros and cons associated with it. I will be describing the EHR mandate, including who initiated it, when it was initiated, the goals of the EHR, and how the Affordable Care Act and the Obama administration are tied into it. Then I will show evidence of research and discuss the six steps of this process as well as my facilities progress with EHR. Then I will describe meaningful use and how my facility attained it. Finally, I will define HIPAA law, the possible threats to patient confidentiality relating to EHR, and how what my facility

The American Recovery and Reinvestment Act made an investment in the year 2009 to encourage the adoption and implementation of the electronic health records (EHRs)(Cite). EHRs incentive payments were authorized through Medicare and Medicaid to clinicians and hospitals when they privately and securely used EHRs for achieving improvements in care delivery by the Health Information Technology for Economic and Clinical Health Act (HITECH). The healthcare organizations are expected to demonstrate meaningful use of EHRs. This rule of meaningful use has been implemented to strike a balance between acknowledging the urgency of adopting EHRs for improving the healthcare system and identifying the challenges that would be put forth

Over the previous eight years, there has been a significant investment of private and public funds to upsurge the adoption of Electronic health records (EHRs) across the nation. The extensive adoption and “meaningful use” of electronic health records is a national priority. EHRs come in various forms and can be utilized in distinct organizations, as interoperating systems in allied health care units, on a regional level, or nationwide. The benefit of utilizing an EHR depends heavily on provider’s uptake on technology. Benefits related to electronic health records are numerous and may have clinical, organizational and societal outcomes. However, challenges in implementing electronic health records has attained some attention, the implementation

Use of EHR (electronic health records) in United States has increased in past years and have gained widespread use in the country. The use of EHR-Electronic Health Records or EMR-Electronic Medical Records and the systems that support them have gained standardized collection of health information and data for patient and healthcare providers. Because of these technologies, healthcare providers now have information about their patients at their fingertips, which has led to better and more accurate care. There are debates on using EHR. According to Mushtaq (2015), one of the most common debate is the use of EHR compliance and the value of these technologies that surround them (Mushtaq, 2015). Providers wonder if EHR use is useful and what is to be gained for the HCP-Healthcare provider. In regards to such debates and ongoing conversations, it is important to understand the definition of meaningful use and whether these technologies have resulted in meaningful use. According to Burchell (2016), The government developed the HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009, which incorporates the meaningful use program (Burchell, 2016). The program has goals that tell us how to use the meaningful use with EMR or EHR. It helps HCP and organizations alike attain, use and keep goals like patient and clinical outcomes, individual patient autonomy, and increased transparency for providers. When these goals are attained and kept it will greatly

Technology has come a long way over the years and continues to advance rapidly. The health care system is greatly affected by the advancements in technology. An example of this would be the use of electronic health records (EHR). In this paper I will be describing the electronic health record system. How my facility has initiated the EHR with following the six steps and describe meaningful use and how my facility is working towards this. Lastly I will discuss how to maintain patient confidentiality with use of EHR, and what my facility is doing to prevent HIPPA violations.

There’s no denying that EHR has advanced the quality of healthcare by improving the way information is accessed and exchanged. But despite these advancements, errors, which were simply not tolerated in paper records, are numerous in EHRs. Because of this, electronic documentation tools have been developed in an effort to increase the quality of clinical documentation, enhance communication between healthcare providers, and improve delivery of care.

With the advent of electronic health records (EHR’s) and The American Recovery Reinvestment Act (ARRA) of 2009, electronic health records have become main stream and a requirement for healthcare providers who treat Medicaid and Medicare patients. An electronic health record (EHR) is a digital version of a patient’s paper chart (Health IT, n.d.). EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. A portion of ARRA provides reimbursements to providers that have EHR’s that are certified for meaningful use. Certified EHR’s meet meaningful use requirements by meeting the government the Health Information Technology for Economic and Clinical Health (HITECH)

In February of 2009, the American Reinvestment & Recovery Act (ARRA) was passed to help the nation modernize its infrastructure. The “Health Information Technology for Economic and Clinical Health (HITECH) Act” was then passed to address the barriers to the adoption of the electronic health record by healthcare organizations (Sandefer, Marc, & Kleeburg, 2015). There are many barriers for healthcare organizations to adopt the electronic health record. These include: “substantial cost, the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing,

Therefore, several authors share some of the same ideas as to what some of the barriers faced during the transition to Electronic Health Records (EHRs) and if these barriers still exist once the transition to a full EHR system is complete. Herrick, et al., 2010, states that currently, there is no hard-core evidence to support the argument that Electronic Health Record (EHRs) and Health Information Technology is the best route for health organizations to prevent errors. In fact, the use of such technology could potentially lead to errors if information incorrectly entered in the system and Haupt, 2011, statement that smart software could help to prevent life-threatening errors better when administering medicines. Whereas, Boonstra & Broekhuis, 2010, states from a physician point a view need the understanding of the possible barriers that faced during implementation of EHRs because there a tremendous amount of literature on the obstacles but no suggestion on how to resolve these barriers have not been viewed. Barriers such as, financial on great startup and ongoing cost, technical and time to train staff and how much knowledge do they have with computer skills and psychological when support needed from vendors, etc. It suggests that once those barriers have been ironed out and a plan has set in place, then the transition from paper documentation to Electronic Health Records (EHRs) may go a lot easier for the healthcare arena physician, nurses and administrative

Electronic medical records (EMR) can improve healthcare performance and cost efficiency in healthcare facilities. Improving healthcare performance includes patient safety, quality of care, and health status of the patients. Patient safety with medication errors continue to escalate, costing health care systems billions of dollars each year (Seibert, et al., 2014). An estimated 450,000 adverse drug events-medication errors that result in patient harm-occur annually, approximately 25% of which are preventable (Seibert, et. al, 2014). Overall, having an EMR helps improve healthcare delivery: no illegible handwriting, information can be shared on an instantaneous basis within a healthcare institution or between institutions, and review of previous

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

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.