I have decided to pursue a career in health information technology. My eventual goal is to get a job in a medical billing and coding setting. I am lucky enough to have a couple of family members that currently work in this field, so I am ahead of the curve in knowing what to expect and where are good places to apply.
In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.
Electronic health records were a technological advancement in the healthcare industry in which paper patient record’s became digital. The transition from paper to digital charting allowed easier, quicker access to patient information for those who were authorized to do so. EHRs are secure and protected with username and password access only. It contains information such as patient medical history, procedures, diagnoses, medications, labs, tests, and treatments. Healthcare professionals and organizations who are authorized to access a patient’s electronic health record can do so at ease via a secure network or online database (HealthIT, 2013).
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
Technology has come a long way over the years and continues to advance rapidly. The health care system is greatly affected by the advancements in technology. An example of this would be the use of electronic health records (EHR). In this paper I will be describing the electronic health record system. How my facility has initiated the EHR with following the six steps and describe meaningful use and how my facility is working towards this. Lastly I will discuss how to maintain patient confidentiality with use of EHR, and what my facility is doing to prevent HIPPA violations.
Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.
While HPMG utilization of health information technology in three distinct manners certainly puts them ahead of many healthcare providers back in 2007, with ARRA and ACA, healthcare providers are required to implement electronic health records in some form. By 2013 over 63% of physicians in the United States adopted electronic health records and another 28% have a system partially implemented or plan to implement one in the next two years (The Commonwealth Fund, 2015). With 91% of physicians either having a system implemented or planning to implement, electronic health records are certainly a system that was replicated throughout healthcare in 2014.
Electronic Health Records (EHRs) is another version of a patient’s medical history, that is maintained by the healthcare facilities or provider over time, and may include all of the key administrative clinical data relevant to that persons care under particular healthcare facilities, including demographics, progress notes, medication, x-rays, surgical history, and etc.(CMS,2012). While the adoption of the electronic health record system seems promising for the healthcare community and having a positive impact on the HIM field with better care and decreased in healthcare cost, and other promising aspects. However, poor EHR system design and improper use can cause EHR-related errors put at risk to honesty of the information in the EHR; causing or leading healthcare facilities and hospital to break that confidential bond they have with the patient. This will cause EHRS to have errors that endanger patient safety or decrease the quality of care that the patients expect from the hospital or healthcare facility (Bowman, 2013). In the paper I will discussed the topics along the lines like managing the Transition from Paper to EHRs, EHRs to redefine the role of doctors, and other ways how EHRs impact will have on the HIM community.
The handwritten documentation has been the usual way of recording medical data since the nineteenth century. However, the fast development of computer technology has led to the advancement and use of electronic medical records (EMRs) throughout the past several decades (Jerant & Hill, 2000). The evolution from a paper to an electronic setting can be somewhat straightforward. The two leading reasons why most facilities chooses to convert to EMRs is patient care and safety. Health-care Information and Management Systems Society (HIMSS) presented its EMR adoption model in 2005 and now tracks the implementation growth of more than 5000 U.S hospitals (Traynor, 2011).
Meaningful use is the adoption and use of certified health record tech, entry/capture of data (vitals, orders), movement of data (transitions of care), report data (to larger clinical systems) (SuccessEHS, 2012). Issues
2008). Another system focused on patient scheduling in a rehabilitation setting (Ozbolt, J.G., Saba, V.K. 2008). Nurses at a California hosptial assisted in developing the first comprehensive hospital information system and helped integrat the system for nursing care planning, documentation, and feedback (Ozbolt, J.G., Saba, V.K. 2008). They developed the standard care plans that are used throughout the world today (Ozbolt, J.G., Saba, V.K. 2008). Another big achievement of this decade was the introduction of the first commercial electronic medical record (Thede, L. 2012). This new system was patient-oriented and was implemented throughout the hospital (Thede, L. 2012).
Communication is the key to relating in all environments. When communication lines are broken, it makes take in jobs and personal relationship suffer. In medical environment communication is key in running hospital, nursing home and community care providers. With technology our communication has advanced because now we have electronic medical records. Electronic medical records are a way of providing the medical staff and insurance on the patient health information and insurance coverage. As stated by About.com, “This also provide the doctors away to for individual patients, access to good care becomes easier and safer when
Advancements in technology have made it possible for people to access medical information, communicate with their doctor, manage and track diseases, seek help, and maintain anonymity. Technology has facilitated the tracking of medical information, for example, Kaiser Permanente uses a computerized system to store and track patient information. Any doctor in a
In today’s medical field technology plays a big role when it comes to patient care. Technology is huge when it comes to giving the patient the best type of quality care when they are in the hospital. In the old days people would just write it down on a sheet of paper and record it by hand, which caused mistakes. Now with the Electronic Health Record those mistakes are drastically declining. Statistics have shown that using the Electronic Health Record has lowered Nursing mistakes as well as improved patient care. Our society has progressed through the years and has been introduced with the Electronic Health Record which has drastically improved our health care system. The Electronic Health Record provides great communication between
Inevitably, health information systems (HIS) affect both patient care and documentation. Consider the following scenario. A patient with hypertension schedules routine appointments with his primary care physician. At every appointment, the nurse documents the blood pressure reading along with the most updated list of medications that the patient is currently taking. After