Electronic Health Record Research Paper

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

Implementation of the electronic health records (EHRs) has been a growing trend in the healthcare field from fear of the unknown to the acceptance of the reality of the EHRs and the actually utilizing the system. The struggle to go live with the EHR was a challenge because change is always a difficult implementation. According to Fickenscher & Bakerman, (2011) Change is a process that is individualized base on one's ability to adopt and the interest on the change. Some people may take longer to understand a process while others will grab the skill within a short time. However, some few setbacks slow down the adoption of the EHRs when it was first implemented, Culture, communication and training and time. Despite

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 difference between theses two medical coding systems that medical practices rely on being financial stability.ICD-9 contains approximately 13,000 codes and ICD-10 will contain a totally 68,000 available codes. The ICD-10 structure code is greatly expanded and the new codes are capable of reporting data in much greater specific. When the CMS mandated the changes to be effective in 2014. The data ICD-10 codes contain is expected to improve the efficiency of healthcare reimbursement and reduce charges of fraud and abuse. The ICD-10 billing will involve an all encompassing alphanumeric systemization. The ICD-10 diagnosis code will always be a letter then numbers. The ICD-10CM/PCS has two consisted parts, ICD-10-CM diagnosed classification system developed by the centers for disease control and prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3-7 alpha and numeric digit and full code titles. ICD-9-cm is very much the same. ICD-10-PCS procedure classification system developed by the centers for Medicare and Medicaid services CMS for use in the U.S. for inpatient hospital setting only. The new procedure coding system uses 7 alpha or numerical digits while the ICD-9-cm coding system uses 3or4 numbers that's the

Health information technology is a familiar entity for most working nurses in the year of 2017. Many nurses, have lived through the transition from paper charting to online charting. This transition has not always been a progression of ease. Change is never easy. The process of paper charting with pen and paper and the use of paper medication administration records have been the routine process for many years. With the new onset of the electronic health record (EHR) many processes have become easier, safer, and more efficient while some tasks have become more complicated, confusing, and more time consuming. The goal of this paper is to describe the electronic health record system, expand on the essence

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

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a system that is used by physicians, and health providers to classify and code all diagnoses, symptoms, and procedures. This system consists of about 68,000 codes, compared to the ICD-9-CM which has only about 13,000 codes. These codes are used to be able to bill patients’ medical insurances. Since there are more codes in the ICD-10-CM there will most likely be less claims. And medical insurance providers will have a clearer understanding of what they are being billed for. Since there are more codes for diagnoses. To prepare for ICD-10-CM, I’m glad I have all my books for reference whenever I may need it. And what knowledge I receive from this class

How will the transition to an electronic health record impact patient safety and quality patient care? It was The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 being signed into law as part of a stimulus package, that started the big push for the use of electronic health records (EHRs). This initiative has been the largest initiative in the US designed to help keep American health care providers delivering higher quality of care to their patients in this computerized world we live in today. Two main areas of concern are patient safety and quality of care the patient receives.

Over the past decade, virtually every major industry invested heavily in computerization. Relative to a decade ago, today more Americans buy airline tickets and check in to flights online, purchase goods on the Web, and even earn degrees online in such disciplines as nursing,1 law,2 and business,3 among others. Yet, despite these advances in our society, the majority of patients are given handwritten medication prescriptions, and very few patients are able to email their physician4 or even schedule an appointment to see a provider without speaking to a live receptionist. Electronic health record (EHR) systems have the potential to transform the health care system from a mostly paper-based industry to one that utilizes clinical

will be able to improve financial outcomes through the application of this system. Additionally, fewer patient errors will mean less legal liability for the organization. The new system should improve efficiency and reduce the time needed to undertake administrative tasks. For healthcare providers, this will mean more time with the patient. In addition, the system should eliminate errors and improve patient outcomes. The

Electronic Health Records (EHR) are just as the name implies, a computerized record of a patient’s current and past medical history. It is maintained by the provider over time, and includes all the key administrative clinical data pertinent to a person’s care (The Government & Health IT, 2013). EHRs can provide a medical story for healthcare providers of the patient’s life. They contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results (What is an electronic health record?, 2013). Unlike paper records, electronic records are easier to retrieved with the click of a button. In some cases, the time it takes

This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the

ICD-10, which is the tenth revision of the International Statistical Classification of Diseases and Related Health Problem, refers to a medical classification inventory for the coding of diseases, their signs, symptoms and causes (Center for Disease Control and Prevention 1). The use of this revised version in the United States is scheduled to begin officially on the first of October 2013. Currently, ICD-10 is being used for diagnosis coding, in procedure coding systems and for inpatient procedure coding.

One of the avoidable missteps often made when a practice implements a new electronic health record (EHR) is failing to train staff adequately. Tom Giannulli, CMI officer for Kareo, told Physicians Practice it's not wise to try to learn a new system and see patients at the same time, going so far as to suggest doing so will ultimately “waste time and increase frustration.” Many industry experts agree with Giannulli. Most warn medical organizations who don't take the time to initiate a full-scale training program on the new technology, they can expect productivity and accuracy to suffer, at least in the short term. Of course, few practices can financially afford to shutter their office for a week of intensive training. Their patients may experience

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. Both computers 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, 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 result from paper-based charting. Obviously, the implementation of clinical documentation is crucial to enhance the provision of safe, ethical, and effective nursing care.