The Electronic Medical Record System

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.

The EMR is a software program used to enter patients information into a computer, which organizes and stores the information. I believe most offices will keep the paper charts in a very safe location or shred it. But I think because of the confidentiality that any and all information or records relating to patients is considered privileged. basically saying keeping all information about the patient confidential.

The Role of Electronic Health Records and Health Information Exchange in the Delivery of Quality Healthcare

The Inner City Clinic is experiencing problems with medication prescribing errors and seeks a resolution to this problem through use of electronic medical records and registration medication reconciliation. The Institute of Medicine reports in the work entitled "Preventing Medication Errors" that the "average hospitalized patient is subject to at least one medication per day. This is reported to confirm previous research findings that medication errors represent the "most common patient safety error." (Barnsteiner, nd, p.1) Medication reconciliation is described as follows:

We live in a world filled with technology. School teachers and college professors use technology to give lectures, health care professionals use technology to keep medical records, or monitor patient’s vital signs, we use technology such as social media, to connect with people and gain acceptance. In 2014, Gary Turk posted a video to Youtube titled Look Up, in which he argues that technology, such as smartphones, causes us to miss out on certain things in life, because we don’t use it in moderation. Technology benefits our lives by making us more efficient in our professional and personal activities.

The electronic health record is the electronic version of a patients’ medical chart (Centers for Medicare & Medicaid Services, 2012). The information included in the electronic health record is the patient’s demographics and clinical health information, medical history, list of health problems, progress notes, medications, vital signs, laboratory and radiology reports, and physician orders. The purpose of the electronic health record is to prevent medical errors and improve care delivery to provide a safer patient environment (McGonigle & Mastrian, 2015).

With the increasing advances with technology in this day in age, there is no surprise that electronic health records will soon be a major component in all hospitals of the Canadian health care system. Assessment of Electronic Health Record Usability with Undergraduate Nursing Students is an informative article, written by Jones & Donelle, about the increased use of electronic health records within our system and discusses its benefits, as well as difficulties nursing students experience with this new type of technology. It is a new method of technology that will soon replace paper charting and will allow access to patients to communicate with their health care providers, manage their health information, schedule appointments, and have access

For a nation to be technologically advanced, the United States (U.S.) is having a hard time overcoming the dark era of utilizing hand written scripts, progress notes, and paper records. In comparison to other countries, the U.S. is lagging behind in the health care system. Even with all the improvements that have been made recently, the U.S. ranked last in 2014 in areas such as access, efficiency and equity compared to Australia, Canada, France Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom (Davis, Stremikis, Squires, & Schoen, 2014). Now, as our nation is trying to improve the quality, access, and proficiency of our health care, concerns have been raised whether the new policies are adequate enough for privacy amongst sharing and obtaining health information. This paper was put together to give background information on how the electronic medical record came about and whether privacy is a major concern amongst the American population.

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.

I understand your concerns regarding the legality of the electronic signature. Electronic health record system have many policies and rules that must be followed in both state government and federal. In 2000 the U.S. Government passed a law that gave electronic signature the same legality as written signature. It doesn’t mean that its signed electronically that anyone can access it and sign it for you. Your signature authentication requires a password, biometric, and unique code this identifies that its you who is the signer in the system. If someone tries to access any documents to sigh them they will not be allowed because the system will not recognize it if it wasn’t you. To be save there are passwords that go along.

The meaningful use law was written into legislation with the sole purpose of providing healthcare providers with funding for implementing healthcare information technology, electronic health records, protecting patient’s health information, and provides patients with greater access and control over their protected health information. Derived from the Health Insurance Technology for Economic and Clinical Health Act (HITECH) that provides funding and incentives for the implementation of electronic health records. Title IV of division B of the ARRA is considered part of the HITECH Act. It addresses Medicare and Medicaid EHR and provides financial incentives to healthcare providers and hospitals that adopt and engage in the “meaningful use” of the electronic health record technology. If this legislation made known, and end-users have a better understanding of the legislation fears and obstacles in adopting this anticipated change can be overcome.

The Electronic Medical Record, or "EMR," is a digital version of the paper charts in a hospital or physician's clinic. The Electronic Medical Record is capable of storing all of the patient's medical history, both past and present. Prior to the creation and implementation of the EMR, all physicians were on paper records. EMR's are far superior to paper records in many ways, most notable the ability to comprehensive data collection, ease of access and transferability, and transparency.

City Hospital, a 200-bed inner-city hospital that has a 30-member primary care physician group that has one hospital-based clinic and 4 clinics dispersed throughout the local community. The purpose of electronic medical records is to improve the efficiency of health care delivery by sharing information of a patient 's history, treatment and outcomes. With this product we will save time, increase reimbursement, decrease physicians, nurses and other staff members wait time and increase better clinical outcomes. EMR generates data that can drive care quality, patient safety and effective financial management. The Center for Medical Services known as CMS has mandated that all facilities will have electronic records for all facilities by October 2019. CMS started making the mandate for people to use electronic medical records for submission for payment for Medicare and Medicaid (Entrikin, Tom. 2012).

In today’s society, time is limited balancing professional and personal lives. People expect the quickest method of communication so they can get back to living their lives, without interruptions. E-mail, the Internet, and cellular phones make communication faster for people to get the information they need. Communication is crucial between consumers and medical providers. Electronic medical records are a mode of communication between consumers and providers. Electronic medical records patient records including medical history, treatments, allergies, lab work, surgeries, and physician’s notes relating to the patient stored electronically on a computer.

Patton-Fuller Community Hospital is a nonprofit Healthcare organization in the city of Kelsey that has provided quality