Evolution of Healthcare Informatics

Nursing informatics (NI) has become a vital part of healthcare delivery and has become a defining factor in the selection, execution, and assessment of technology that supports safe, exceptional quality and patient-centered care. Nursing has become so uniform. The data in patient records has become a valuable resource and has improved assessments and overall patient care. Before the launch of nursing informatics throughout the second half of the 20th century there were not any real standards for language. The use of data restricted the function and

The advancement in technology has rapidly transformed the world today, and the increase in the number of web-enabled devices has completely changed peoples ' lives especially the way they communicate. Electronic Health Record system, which is a digital copy of a patient’s medical history is one of the revolutionary ideas that have come with this advancement. Electronic Health Records (EHRs) are instantaneously updating records that are patient-centered designed with the aim of providing real-time information to the authorized users (Cohen, 2010). It contains all the patient’s information that is in the hand of the medical providers including their medical history, treatment dates and types, immunizations conducted to the patient and their dates, radiology images and all the laboratory results from the tests conducted in the past. All this information is held in a digital format and can only be updated by authorized users who are stationed in the medical facilities. Electronic records are designed to make it easy for different health providers and organizations to share patients’ information which streamlines their operations since all the necessary information and history can be accessed from any location at any time.

Abstracting in the Health Information Management (HIM) profession means “to capture the core of what defines” or summaries the patients chart and review for accuracy (Henriksen, Fanhoe, & Mishra, 2014, p. 3). Medical records tell the story of who, what, when, why and how for the patient. Abstracting can further be defined as “a process of revealing a critical essence of some real object that exists by removing everything except a finite number of its key elements” (p. 4). This process is important for HIM because it allows for needed data to be extracted for further analysis and comparison for quality improvement and training.

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

Although handwritten records are still the mainstay of clinical record keeping, many medical professionals believe that the increased use of information technologies has the potential to effect healthcare for the better. For example, Dr. Daniel R. Masys said, “Against a background of an explosively growing body of knowledge in the health sciences, current models of clinical decision making by autonomous practitioners, relying upon their memory and personal experience, will be inadequate for effective twenty-first-century health care delivery.” While keeping in mind how far manual records have gotten us, we need to realize that information technologies result in better data correlation and management.

Paper-based health records have existed since the time of Hippocrates. The most significant change in paper-based health records occurred in the 20th century with the development of electronic health records (EHRs), due to evolution of technology (Rocha & Rocha, 2014). The development of EHRs began in the mid-1960s. Since that time, EHRs have continued to advance. Many institutions are now placing a greater effort in the utilization of this advancing technology (Atherton, 2011). The main purpose of EHRs is to increase efficiency of care and organize and improve quality of data storage through new resources and applications (Rocha & Rocha, 2014). EHRs play a vital role in the healthcare system, patient care, and

In recent years, there has been a growing interest in the application of biomedical informatics in many aspects of the healthcare system. This is due to an increasing recognition that a stronger healthcare information system is crucial to achieve a higher quality care at lower costs1. Biomedical informatics is defined as “the scientific field that deals with biomedical data, information and knowledge-their storage, retrieval, and optimal use for problem solving and decision making.”2Biomedical informatics plays significant roles in the healthcare system and it has been applied in various ways in the healthcare system, specifically in the aspect of health care information system such as electronic medical record (EMR), personal health record (PHR), computerized provider order entry (CPOE) systems, bar-coding medication administration systems, telemedicine, telehealth, and administrative information systems 2.

It is hard to take a snapshot of the current technology used in healthcare as tomorrow a new innovative idea is right around the corner. A major change that has occurred over time comes from the use of electronic health records (EHR). Electronic health records usage has been on the rise for several years. It has been used by physicians, ambulatory staff, and HMOs. Since data can be easily altered the copies that must be certified for any medical provider to reference. There is a criterion for the composition of this data due to the exchanging of patient information within an interoperable medical

While many people believe that health information exchange is a relatively new thing, it has been around for over four decades. However, in the beginning phases it was nowhere near as complex as it is now. Sometime in the middle of the 60’s, an early form of a data processing system was formed and it focuses on clinical data management. This system began to catch on even though they were nowhere near as sophisticated and or functional as the health records in today’s time.

Many if not all healthcare systems are transferring paper-based record systems to electronic systems (Rezaeibagha, F., Win, T K., Susilo, W., 2015). Electronic health record systems or EHR are providing a better quality of services to patients in health care settings. In US, there is an estimation of 1.5 million patients harmed due too medication errors, yearly, with an estimation of 400,000 adverse events that could have been prevented (Agrawal, A. 2009). IT system based electronic health records are being implemented to improve access to information, while organizing the information, and linking it together for perfect patient outcomes. Often times

Healthcare is a complex entity that encompasses a variety of specialties necessary toward meeting the needs of patient seeking clinical services. There are multiple communications necessary to efficiently meet patient needs. For many years detailed documentation, progress notes, specialty consults, and physician orders have been hand written. The legibility of this documentation was often illegible, and difficult to decipher, which resulted in clarification orders and often delays. The electronic medical record was introduced approximately 50 years ago with an ultimate goal of compiling healthcare information for immediate and future reference (Keller, 2016). Since the electronic medical records was initially implemented multiple versions have since been created. Successfully implementing the electronic medical record, requires a great deal of research to ensure that the specifications align with the organization’s short and long term goals.

An electronic health records (EHRs) has the simplest, digital (computerized) versions of patient 's paper charts. But, (EHRs) when fully up and running are so much more than that. EHRs are real-time patient-centered records. They make information available instantly "whenever and wherever it is needed." And they bring together in one place everything about a patient 's health. EHRs can: contain information about a patient 's medical history, diagnoses, medications, immunization dates, allergies, radiology images, lab and test results; offer access to evidence-based tools that providers can use in making decisions about a patient 's care, automate and streamline provider’s workflow, increase organization and accuracy of patient information, support key market changes in payer requirements and consumer expectations. One of the key features of an EHR is that it can

The safety of the patient is very crucial when caring for patients and the community. The use of informatics would improve Patient safety, such as the use of medication barcode administration, (BCMA), and Computerized Provider Order Entry (CPOE) are few informatics implementations that would help with patient safety in the healthcare system (Sewell, 2015) Cost is another driving force towards the use of informatics. With the cost of health at its highest, consumers and employers would use informatics to access the quality of care, compare prices and also compare providers. Medical errors in healthcare setting cost a hugged amount of money. “Electronically prescribed drugs are more legible, thus making it less likely that drugs would be wrongly administered to patients (Chih-Piing et al, 2016)”.The use of informatics will help reduce some of this error which would save the government, hospital, and consumers from extremely high

The Electronic Health Record (EHR) is a vital tool in accessing the important details of the patient, the basic identification such as full name and birthday, the baseline vital signs and the past medical history as well as the current medical or surgical information. The integration of the EHR according to “the Agency for healthcare Research and Quality (AHRQ) study highlighted the overall economic value” as well of having an EHR (McGonigle & Mastrian, 2015, p. 255). The American Nurses Association (ANA) emphasized its goal of nursing informatics, which is to “improve the health of populations, communities, families, and individuals by optimizing information management and communication” in delivering excellent patient care utilizing the

Because clinical and qualitative outcomes are primary components of health delivery, health professionals must practice caution when operating health databases. Many are concerned regarding safety issues resulting from the clinical errors that occur from poor IT design, or insufficient operation by staff. These issues are reasons “IT systems must be designed to optimize clinical workflow and must be continually improved” (Ash, Berg, & Coiera,