Recent technological advancements have drastically changed how care providers manage data and deliver services. [1] For this reason, entry-level and veteran nurses learn new technologies, while nursing schools develop new curriculums that serve the new caregiving environment. The most notable changes have occurred in the healthcare information technology (HIT) field, where providers use powerful software and hardware to manage patient records. This development has in turn advanced the informatics field, which combines HIT databases – such as electronic health records (EHRs) with institutional administrative data and helps organization perform more efficiently. Informatics practitioners use HIT to maximize the utility offered by EHRs - …show more content…
The transparency eliminates errors and risks, such as conflicting prescriptions and treatments. Care providers use monitoring technology to trigger alerts when such discrepancies arise in patients’ electronic health records. Faster Lab Results Electronic health records allow caregivers to retrieve patient information faster than using conventional methods, facilitating timely test scheduling and treatment. [4] Furthermore, caregivers can access test results as soon as the results become available. Increase Patients Information Accessibility By law, American citizens have the right to access their medical information to check for and correct errors and omissions. [3] To this end, some care providers offer patients online access to their medical records. The practice increases information transparency and, in many cases, allows patients to fin answer their own queries quickly. Increased Prescription Efficiency While EHRs greatly reduce drug errors, some mistakes still occur. [5] Mistakes typically happen while administering, dispensing, prescribing and transcribing medications. Electronic information management allows caregivers to identify areas for improvement and increase patient safety. Streamlined Records Administration Electronic health records replace the paper patient charts typically used during most care provider visits. [3] As more providers adopt EHR
Electronic health records can lessen the disintegration of care by refining care coordination. The use of electronic health records will deliver providers with accurate information. This is especially important for those that see multiple specialists, and enable a smooth transition between care settings and receive treatment in emergency
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
Electronic Health Records (EHRs) are an important component in health care reform, but do they really bring efficiency to the practice? The extent to which practices use EHRs vary from the very basic (entering clinical notes and viewing results) to the intermediate (using e-Prescribing to indicate adverse drug prevention and provide suggestions for alternative drugs) to the advanced use (including lab and radiology order entry with testing guidance, capture of electronic charge, and evidence-based guidelines).
There’s no denying that EHR has advanced the quality of healthcare by improving the way information is accessed and exchanged. But despite these advancements, errors, which were simply not tolerated in paper records, are numerous in EHRs. Because of this, electronic documentation tools have been developed in an effort to increase the quality of clinical documentation, enhance communication between healthcare providers, and improve delivery of care.
We live in a digital age where everything from photos to important documents is saved or stored online. This includes the use of electronic medical records. The electronic medical record (EMR) is useful in assisting physicians to have a complete and thorough health history of the patient. The EMR serves as a continuity of care from one hospital to another within the same organization (Hsieh, 2014). Consulting physicians also have quick access to recent diagnostic imaging, progress notes, and lab results. EMRs can help manage patients with chronic disease states, aid in data collection for use in research, and prevent adverse drug events (Hsieh, 2014).
These systems will also help cut down on medication errors by comparing the patient’s to medications or interventions so that it is given to the correct patient. Also documents the care given so there would be no human error in the case of questioning whether care had been given as long as the caregiver documents in the record. These features of the electronic health record are in place to promote patient safety by reducing errors.
But as noted previously, more is needed than standardizing these processes. Health care providers (physicians and hospitals) should embrace electronic health records (EHRs) and should integrate appropriate information from billing systems with clinical information (the recording and analysis of clinical services) from EHRs (Wikler et al., 2012; Cutler et al., 2012). To address concerns that occur due to accessing medical records, the secretary of health and human services could expand criteria under the Health information Technology for Economic and Clinical
Slide 11: Human errors, such as medication errors or allergy errors, are minimized with alerts on the electronic health record. The electronic health record has shown to reduce the number of missing charts (82%), and improves data accessibility to patient records and documentation remotely (75%) (Narisi, 2013). By eliminating paper charting, the EHR makes all patient’s data and information available at all times to all physicians. The EHR improves patient care delivery by reducing the error of hand-written orders and allows for other physicians to access the order. This is great for when the doctor orders a medication to start stat, and puts the order into the EHR, so the nurse can start the medication right away (Palma, 2013).
Electronic health records is a major component in the United States health care system. It has been proven to improve health care quality by saving time and reducing
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an
Electronic health records (EHRs): Medical records are now kept in an electronic versus a paper chart. All health information regarding past and current medical history, treatment plans, and medications are kept in the EHR. The system also allows sharing of medical information from provider to provider as needed. Many HER systems have a feature to allow patients to log into a patient portal to review lab results, diagnostic tests, plans of care, and email access to the provider
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
Although the EHR is still in a transitional state, this major shift that electronic medical records are taking is bringing many concerns to the table. Two concerns at the top of the list are privacy and standardization issues. In 1996, U.S. Congress enacted a non-for-profit organization called Health Insurance Portability and Accountability Act (HIPAA). This law establishes national standards for privacy and security of health information. HIPAA deals with information standards, data integrity, confidentiality, accessing and handling your medical information. They also were designed to guarantee transferred information be protected from one facility to the next (Meridan, 2007). But even with the HIPAA privacy rules, they too have their shortcomings. HIPAA can’t fully safeguard the limitations of who’s accessible to your information. A short stay at your local
Electronic medical records had a great impact in the ushering in of the age of Nursing Informatics. (Himss, 2010)EMRS present healthcare professionals with the ability to retrieve and organize data in a quick and efficient approach. With information so readily available, patient safety increases and we know that patient cost goes down. This happens because patient medications, allergies, history, demographic, and treatment information is more collectively available.
Another big plus of the EHRs is that studies have shown that it has helped providers improve accuracy of diagnoses and health outcomes (Couch, 2008). For example, nurses could have reliable access to patients complete health information and have pictures which would help with whatever problem they might encounter. EHR doesn’t just keep patients medications and allergies, it also check for problems whenever a new medication is prescribed and it also alerts the nurse of potential problems (Couch, 2008). EHRs can also tell the nurse if potential safety problems occur, which helps them avoid more serious consequences for patients, which can lead to better outcomes. The EHRs can also help nurses quickly identify and correct operational problems, which compared to the paper-based setting, those kinds of problems would be more difficult to correct. It can also help