Electronic Health Record ( Ehr ) System

and save patient data such as allergies, health history, lab results, health center visits in the electronic health record (EHR) and securely communicate these records with other health entities and governmental agencies (Oracle, 2010). With the ultimate ambition being the establishment of a more effectual, patient centered health care system that decreases provider’s administrative expenditure, improving coordination of care among providers and increasing patient’s participation in their own health care (Galbraith, 2013). This article will supply a synopsis of the meaningful use program, the connotations of its core standards and present proposals for further measures.

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.

EHR was created to have a technical way to securely exchange private and personal medical health information in hopes to improve the quality of care, decrease medical errors, limiting paper use, reduction of health care cost, and increasing a person access to affordable health care. A mandate was created for EHR stating that health records can be accessible to all facilities with patients having the capability to access their own health records at any time. Ameliorating the quality and convenience of care given to a patient, allow for cost saving measures, engage the patient and family to participate in their care, improve accuracy of medical diagnosis, and enhance the efficiency of the overall outcome of the patients’ health.

The federal requires the healthcare organizations to adopt and demonstrate the use of electronic medical records (EMR) or the electronic health records (EHR). They contain patient’s medical history and it

In the recent years, EHR implementation has been one of the biggest change that occurred in the health care delivery system. The adoption of EHR system which aims to improve the quality of healthcare, however, has met a lot of issues and barriers that are detrimental to its success. Thus, for any healthcare organization to achieve a favorable outcome after the EHR implementation, numerous factors have to be examined. Merrill (2010) has listed down the top ten factors for a successful EHR adoption. It includes right leadership, shared vision, right culture, governance, physicians, nurses and key stakeholders are engaged early and accountable to lead the clinical transformation, resources, clinical content standardization, realistic timelines and expectations, effective training and communication plan, and right vendor partnership relationship.

EHRs adoption is an essential part of improving patient safety and the quality of health care by reducing errors, allowing access to complete and accurate medical information to produce better patient outcomes. Although, it seems like a win/win situation there are still some challenges that appear when implementing an EHR. Some challenges would be Time, Cost, Work- Flow Distribution, Security/Privacy, and Interoperability just to name few. Interoperability is defined as the ability of a computer system or software to exchange or make use of information, which can create a major issue for any organization if these systems are not communicating properly. Security and Privacy are always a concern because implementing HIPAA measures is not an easy task. Not only do you have to comply with the federal level organization still need to recognize state laws which can often be more stringent. Especially, when you need to cover areas such as mental health, drug and alcohol services, genetic testing, HIV, and family planning issues. Change management would be enacted to overcome any issues involving process change resistance. It is a methodical approach and application of knowledge that use tools and resources to deal with this type of change. Methodologies would

In efforts to reform the United States healthcare system and create a nationally unified data exchange system the federal government has established an incentive program to eligible professionals and hospitals. The federal government has turned to certified electronic health record (EHR) technology to help facilitate the process of broadening health IT infrastructures. The federal government views EHR system used in meaningful ways as the key to reforming the healthcare systems. Meaningful use of the EHR systems can also improve the overall quality of healthcare, insure patient safety, as well as reduce the cost of healthcare to individuals (Bigalke & Morris, 2010, p. 116).

The use of technology can be seen everywhere in the world today. One area which has seen a big push to add technology is the healthcare industry. Healthcare has now progressed to the age of electronic health records (EHR). The purpose of this paper is to discuss the evolution of the EHR, including the EHR mandate and the role of the Affordable Care Act in this mandate. It will discuss the EHR plan at Hackettstown Medical Center (HMC) to include the progress HMC has made with the mandate. This paper will discuss meaningful use and HMCs status with meaningful use. Lastly, the paper will define the Health Information Portability and Accountability Act (HIPAA) and what HMC is doing to prevent HIPAA violations.

Getting successful universal EHR is not just technology selection, implementation question it needs to address many other aspects such as physician’s acceptance, policy/laws, incentives, security, and privacy and training issues before we can concentrate or focus on technology selection and implementations. The ecosystem should be ready with all these critical elements addressed only then successful EHR implementation can sustain in US. First and foremost there is a need to have consistency around the state/federal and HIPPA regulations which defines security and privacy issues in US. Due to conflicting requirements in these regulations mass acceptance of any medical system/technology cannot be effectively done. Second biggest issue for universal EHR adoption is the acceptance of EHR by physician’s communities. The benefits of EHR has been identified and acknowledged by medical communities at large however the rate of adoption and use after implementation is sluggish. The biggest common contributor for implementation, design and use of EHR systems is physician. Physicians should be properly trained and emphasis on continual education should also be placed through continuing education credits. Unless small physician office (stand-alone offices) buy-in the adoption of EHR no matter what technology and processes we have in place, EHR won’t be universally accepted and the entire benefit and value associated with EHR can be realized with universal acceptance of EHR. Thus need for

Considering the great advances in technology, EHRs prior to January 2009 were underperforming. Often the EHR simply resembled the provider’s unique approach to healthcare. The technology existed, however the healthcare industry was not ready embracing the capabilities of the EHR. EHRs require standardization and each hospital had its own version of practicing medicine. It became apparent healthcare providers were going to continue business as usual; therefore the benefits linked to the capabilities of the EHR went unrealized. Indeed it is interesting the amount of time and legal maneuvers it took to spark the use of EHRs in hospitals. It was apparent government intervention to jump-start the EHR was inevitable. On January 9, 2009 passage of the Health Information Technology for Economic and Clinical Health legislation (HITECH) opened the gateway to technology and implementation of the EHR.

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

Electronic Health Records have enhanced how information is stored and transmitted in the healthcare setting. They are a safe and much more secure way of maintaining records. In addition to security, it speeds up service times for patients and records can be transported through the click of a mouse. EHRs are now mandatory as a directive set by the Affordable Care Act (ACA) and all healthcare organizations must conform or face a heavy penalty (EHR adoption, 2011). Despite the fact that many organizations do not like change, there are some positive outcomes that could occur if an organization switches from the “old” way of doing things to a new EHR system. By implementing an EHR system, an organization could see more money to the bottom line. Many organizations have been noticing that EHRs are allowing them to become more efficient and they have seen business grow in recent years. Dr. Larry Garber a physician and medical director for informatics at Worcester, Mass based Reliant Medical group said” The $24 million EHR investment was worth every penny, the medical group has seen return on investment, big revenue boosts and a huge increase in compliance and clinical results. (McCann, 2013). EHRs can be designed by the individual organization. They don’t have to come in a one size fit all category. Dr. Gerber spoke about his practice designing an EHR feature for radiologist that allowed them to correct the percentage of incorrectly ordered

The general guidelines of the policy entail the meaningful use of EHR including using certified EHR in meaningful ways like e-prescribing, using certified EHR technology for health information exchange electronically to improve health care, and using the technology for information submission to promote clinical quality (Habib, 2010). The policy should also guide the meaningful use of EHR towards improving care coordination, reducing healthcare disparities, engaging, patients and their families, and ensuring adequate privacy as well as the security of patient

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.

The Office of the National Coordinator for Health Information Technology (ONC-HIT) has defined a list of functional considerations that must be considered when implementing an EHR into practice. Numerous facets must be taken into account, such as maintaining access controls, protecting patient information while allowing patient access, all while following the standards set by HIPAA must be a priority in any EHR system. Research by Sun, Zhu, Zhang, and Fang (2011) shows that patients have been resistant to acceptance of an EHR system without assurance that their information will be safeguarded, used properly, and appropriate