Electronic Health Record Article Summary

purpose of this paper is to review the electronic medical record and analyze its impact on

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.

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

In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.

As the national health care system transitions to the electronic health record (EHR), it is important to recall the impetus to this reform. Prior to the implementation of the electronic health record, the national health care system encountered many problems that impeded quality patient care. There was not a standardized formal structure with the process. Consequently, it lacked communication across disciplines and among providers and

“… longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting”. Included in this information are patient demographics… reports. The EHR automates and streamlines the clinician 's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, and related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting.”(GAO, 2010)

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.

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

Overall, the purpose of this paper was demonstrated the development of electronic health records and clinical documentation that is used by healthcare practitioners to provide the quality care. The Clinical Documentation has focused on providing care to patients and sharing patient information between healthcare providers and patient medical record to track their conditions. Essentially, future technologies will reduce the dependence from medical paper based industry to use fully an electronic clinical documentation and significantly contribute to these changes and assists health practitioners in meeting professional and organizational goals. This will provide a more efficient infrastructure, and it would be more beneficial for health care when the technology advances, which is helpful towards all patients, the care teams, and health care organizations.

“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

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.

Healthcare across the world has changed drastically due to its changing laws. Only until recently were all patient health records created on physical paper. Technology has made a significant change to the way health records are communicated today. As of 2015, any physician who accepts Medicare and Medicaid is required by law to transition the medical records of these Medicare/Medicaid patients from paper to a certified electronic medical record system. The government regulates this by mandating physicians to make meaningful use of electronic health records. The purpose of meaningful use is ultimately to improve care coordination, and population and public health, maintain privacy and security of patient health information, better clinical

Electronic medical records (EMR) software is a rapidly changing and often misunderstood technology with the potential to cause great change within the medical field. Unfortunately, many healthcare providers fail to understand the complex functions of EMRs, and they rather choose to use them as a mere alternative to paper records. EMRs, however, have many functionalities and uses that could help to improve the patient-physician relationship and the overall quality of patient care. In order for this potential to be realized, both the patient and the healthcare provider must have a deeper understanding of EMR purpose and function. In this paper will highlights the historical developments and its potential effects on the patient physician relationship in order to

Electronic health records (EHR’s) have many advantages, but there are plenty of disadvantages. EHR’s were created to manage the many aspects of healthcare information. Medical professionals use them daily and most would feel lost without it. Healthcare organizations were encouraged to adopt EHR’s in 2009 due to the fact that a bill passed known as The Health Information Technology for Economic and Clinical Health Act (HITECH Act). “The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice”, (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012).