Electronic Health Care Field Report

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.

The Health Information Technology for Economic and Clinical Health Act (HITECH Act) was passed as part of the American Recovery and Reinvestment Act on February 17, 2009. The road to patient-centered care was paved with the passing of the HITECH act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use EHRs privately and securely to achieve specified improvements in care delivery. If providers do not become meaningful users of EHRs by 2015, penalties will be triggered through reduced Medicare payments. These provisions aim to create a nationwide electronic health system that is efficient and secure to improve health outcomes and lower the cost of healthcare. To accomplish these

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

Furthermore, during a medical emergency, physicians, or nurses who do not have time to access a computer for terminal cases can just simply grab patient’s chart (Tsai, Jack.2008). It’s like when a time is of the essence, paper records can make a difference. In addition, with paper health record it is stored in either a big warehouse or lock cabinet and only authorized personnel can obtain the medical records.

Lastly, Electronic Health Records increases the efficiency of the medical practice. EHRs are more efficient because they reduce redundant paperwork and have the capability of interfacing with a billing program that submits claims electronically. It also improves medical practice management through scheduling systems that link appointment directly to progress notes, automated coding, and managed claims and many other shortcuts. In a survey done on Doctors, 79 % of providers said with EHRs, their practice functions more efficiently (HealthIT.gov). Communication with other clinician, insurance providers, pharmacies and diagnostic center is faster and trackable. The increase in communication cuts down on lost of messages and follow-up calls. In addition, the communication of information between several health agencies also prevents the patient from needing to repeated examination. Because EHRs contain all of the patient’s health information in one place, it is less likely that

Something to question is new electronic health records helping staff take care of patients or is it a burden. Nursing documentation is always necessary because it provides a reflection of what nurses do for their patients. Documentation helps ensures a flow with patient’s treatment team (Linton & Moon). When documentation is not done correctly or efficiently due to the new technologies it can place the patient at increased risk and added cost to the hospital. Many nurses feel too much time is spent on electronic documentation and not the patient. Nurses know that failure to document is hard to defend in court (Morales, 2014). Having standardized documentation in place can dramatically ensure that patients are getting taken care of, and not have to worry about missing or forgotten documentation and potentially finding health trends in the documentations (“The importance”, 2015). New documentation requirements are effecting nurses in a good way to make sure their care that they provide is being reflected on and noticed.

There are many advantages with the implementation of electronic medical records for the patient. One important advantage is the ability for the patient’s medical record to be shared amongst the patients other physicians. Information that can be shared includes recent labs, diagnostic testing, and prescribed medication. Another advantage is patients are provided access to certain medical information in his or her medical record through a patient portal. This allows patients to have a more active role in their health care. One disadvantage for patients is many feel that once electronic medical records are implemented, office visits become less personal due to the medical assistant, nurse, and/or physician is too busy answering questions on a computer or tablet.

Under the 2009 American Recovery and Reinvestment Act, up to $27 billion in incentive payments will be given to doctors, hospitals, and other providers who adopt and make meaningful use of these health record systems. Through the implementation of the electronic health record, the organization’s management of the patient’s health care records will become more efficient. There will be improvement of revenue cycle management, lowering of costs, improvement of patient care and safety, increased efficiency, decreased paperwork, automating chart distribution, and the ease of compliance reporting and adherence. It is imperative that the organization’s culture support this change because there are many major stakeholders that this change will affect.

The major change from traditional systems to electronic record systems in the healthcare field within the last couple decades has made a huge impact. Patient records, risk management, planning, staff, and more in the organization are affected by the IT staff. “The penetration of Internet access, mobile technologies and social networks collectively offer a future in which it is possible to deliver highly personalized care without necessarily having to do it in person, or even with a doctor.”(Healthcare IT News, n.d.) Many hospitals use paper records for patients long after electronic record technology was available. According to forbes.com in an article published two years ago, less than 2 percent of all healthcare organizations within the United States had and properly deployed information systems.

As the healthcare landscape continues to shift and evolve, public health departments find themselves facing numerous complex challenges. This makes it imperative that local health departments and individual providers work together to improve the health of their communities.

Because of the meaning use requirements imposed by the govenrment, an electronic medical record is an integral part of all medical practices. The staff nurse discussed the safety benefits of the electronic medical records as it relates to the patient. The clinical administrator concentrated on the practice management and billing components of the computerized system as well as the quality data that can be captured.

National health database mandate will improve the diagnostics and outcomes for patients. Patients receive optimal medical care when the person should be able to obtain inclusive data. The providers can access their patient’s records at the point of care. Electronic Health Records (EHRs) “not only keeps a record of a patient's medications or allergies, automatically checks for problems whenever a new medication is prescribed or alerts the clinician to potential conflicts” (Benefits of EHRs n.d.). Any information recorded in an EHR by the primary provider is obtainable if the patient is in an emergent situation. It allows the clinician in an emergency department access

Clinical Documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy and to direct care of the patient. Both Computer systems and EHRs can facilitate and improve the clinical documentation methods, which is beneficial for all patients, the care teams, and health care organizations. In this case, clinical documentation improvement has a direct impact on patients by providing quality information. However, the new technological change can also address the health care system efficiencies that differ from paper-based charting. Obviously, the implementation of clinical documentation is essential to enhance the provision of safe, ethical, and effective care.

Medical records play an essential role at any hospital, because it is considered as a depository of patient's health observations, analysis, and physical examinations. Since the 1920s, paper medical records have gradually grown all over the world. They are easy to use for senior doctors, nurse, physicians, and anyone with medical expertise, and all of them can use it without any additional skills. It revolutionized the field of medical services, which benefited both patients and medical service providers.

Nurses have their documenting tools that help them document triages, vital signs, assessments, past medical and surgical histories as well as any pertinent family or social history. This system will help doctors to improve their practice performance which will give them more time with the patient to maximize their understanding of the patient’s problems. This system also helps unit clerks and emergency department technicians to see their orders in a timely manner and be able to help the patient quicker than before.