Essay Hybrid Health Record

The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies. The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. (Huston, 2013)

Electronic health records (EHR) are health records that are generated by health care professionals when a patient is seen at a medical facility such as a hospital, mental health clinic, or pharmacy. The EHR contains the same information as paper based medical records like demographics, medical complaints and prescriptions. There are so many more benefits to the EHR than paper based medical records. Accuracy of diagnosis, quality and convenience of patient care, and patient participation are a few examples of the

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.

The contents of a legal health record cannot be universally determined because all healthcare organizations have various needs. Therefore, healthcare organizations are expected to define what constitutes a legal health record for their organization. While each organization's legal health record will not necessarily include the same type of documentation, they all must meet the

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.

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

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.

Despite some barriers and challenges of EHR adoption, transitioning our office to paperless has become inevitable. Timely adoption of EHR would help our clinic receive incentives, merge paper records into the new database, and better organize patient information. In order to ensure the most seamless implementation possible, meticulous planning will be a must.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a US law aimed to advance the portability and continuity of health insurance coverage in both the group and individual markets, and to combat waste, fraud, and abuse in health insurance and health care delivery as well as other purposes26. The Act defines security standards for healthcare information, and it takes into account a number of factors including the technical capabilities of record systems used to maintain health information, the cost of security measures, the need for training personnel, the value of audit trails in computerized record systems, and the needs and capabilities of small healthcare providers. A person who maintains or transmits health information

This journal entry is a reflection of research on the Health Insurance Portability and Accountability Act (HIPPA). Enacted by Congress in 1996, HIPPA was created to “modernize health information exchange” (Solove, 2013). For the consumer, HIPPA sets rules which protect the privacy of health information, to be followed by health care providers and insurance companies. It also gives consumers rights over their health information, such as obtaining a copy, making sure it is accurate, and to know who is or has seen their health information (Office for Civil Rights, n.d.). The modernization of health information exchange, came out of a concern as technology advanced, and computer data bases were now collecting personal health information.

Federal laws require many of the key persons and organizations that handle health information to have policies and security safeguards in place to protect your health information — whether it is stored on paper or electronically.

As part of this valuable heath care system, the patient’s medical record creation and process prove to be one of the most important aspects of a sound quality control plan. According to Bowie and Green, “a patient’s health record serves as the business record for a patients encounter with a physician, and contains documentation of all health care services provided to the patient” (Essentials of Health Information Management, 2016). “Although ones medical record is the property of the provider, as governed by federal and state law patients have a legal right to access its contents for review,” as well as request copies for their own personal files (Bowie and Green, 2016, p. 79). There are laws in place stating that “only authorized individuals may make entries in a patient’s medical record,” and they also recommends that “anyone documenting in the health record should be credentialed or have the authority and right to document as defined by the organization’s policy” (Bowie and Green, 2016, p. 85). These statements mandated by The Joint

The correlation of increased potential patient rights violations and sensitive personal health data among electronic medical records than paper records is growing at an alarming rate. An estimated 52,000 public comments was reviewed by the Department of Health and Human Services requiring privacy regulations governing individually identifiable health information since the passage of Health Insurance Portability and Accountability Act of 1966 (HIPPA). The individually identifiable health information includes demographic data that relates to the individuals past, present, or future physical or mental health condition. In addition, the provision of health care rights of the individual, confidentiality, protection of

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).