The Provider And Patient Attributes

In today’s society, the accuracy of health information, the availability of health records, and the professional resources in which one live are vital in decision making for health conditions. Meaningful Use (MU) is a program developed by CMS Medicare and Medicaid that awards, incentives in the health care industry in which the certified electronic health records (EHRs) are used to improve patient care (Practice Fusion, 2016). These incentives are for professionals that care for about 30% of their adult patient volume or 20% of their children’s volume for Medicare and Medicaid patients (CMS, 2016). In addition, adjusting from paper charts to electronic charts of patient’s information is beneficial for MU. Furthermore, the American

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)

In 1974, the federal government adopted the Uniform Hospital Discharge Data Set (UHDDS) as the standard to help improve the uniformity and comparability of hospital discharge data, the principal diagnosis, and other diagnoses for hospital procedures; including comparable data that could help to determine which hospitals were best at treating patients and for reporting inpatient data in acute care, short-term care, and long-term care hospitals. This dataset works towards a standardized system of reimbursement for the federal government nationwide which in turn could lower costs, UHDDS helps in collecting general information pertaining the patient and the specific care including the age, sex, and race of the patient. The data elements are collected

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

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

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

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (Ehlke & Morone, 2013). The incentives from both of this articles will result in the delivery of quality care to many individuals in

It has only been within the last five years that health information management (HIM) has experienced exponential changes, due to the healthcare reform. The electronic health record (EHR) is connected to health information exchanges and other systems of interoperability. The timely completion of charts, coding and release of information (ROI) has become much more efficient with the electronic record. Traditional HIM functions will just be transformed and will always be an integral part of successful patient care. Professionals must be flexible and willing to adapt and even generate change. As Health Information Technology continues to evolve, so will the roles

Another beneficial feature of EHR systems is that they allow different authorized professionals to access your information from anywhere at any point in time. If a patient checks into the Emergency Room, is moved to Radiology for imaging, then moved to Orthopedics for surgery and finally placed in a bed for recovery, each individual throughout that process will have access to that patient’s medical records without having to communicate with each department. This fosters an

Adoption is the average of a provider’s Computerized Provider Order Entry percentage (CPOE) and Electronic Documentation percentage (E-Doc). Patients Seen is a metric meant to determine how many “meaningful interactions” with patients a provider had in a given timeframe. A meaningful interaction is one where a provider writes a note for a patient. The Adjusted Time in EMR metric is defined as the amount of time in EMR per patient if the provider was at 100% CPOE and 100% E-Doc Authored. It is a statistically predicted number based on the user’s current level of efficiency and extrapolating it up to a maximum adoption level. A specialty is determined by the primary specialty designated by the provider when registering for an NPI with CMS. This is used to compare clinicians to their peers. A facility is defined in as the facility location in Cerner Advance. A provider’s time, patients seen and adoption metrics are all allocated to a facility based on the patient encounter in which they perform the work in Cerner Advance. The venue concept is meant to represent one of three venues of care in which a provider might interact with a patient. Depending on the details of the encounter being viewed in the EMR, either ambulatory, inpatient or emergency is attributed to that provider’s time. Each encounter has an encounter type, which is linked into an encounter class, which is then grouped into a venue. Benchmarking is used to provide context into the data based on the user’s

In our report we show the importance of patient provider relationships and the impact of the patient centered relationships.

“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 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.

Having a single view of the patient and their treatment and recovery plan is invaluable in ascertaining which are the most and least effective tactics in treatment. The 360-degree view of the patient and the many processes supporting them is crucial for increasing the accuracy, effectiveness and performance of treatment programs over time (Blakeman, 1985). Computerized management systems are critical for organizing, analyzing and translating the massive amount of data captured on patients, treatment and recovery processes, and the use of supporting IT systems to optimize patient health and organizational provider performance (Peshek, Cubera, Gleespen, 2010). The ability to aggregate and intelligently use all available data, information, patient-based and process-generated data to deliver higher levels of quality care is possible when computerized management systems are used throughout healthcare organizations.