The National Alliance for Health Information Technology, 2008, defines electronic health records (EHR) as an electronic record of health-related information on an individual that conforms to nationally recognized interoperability stands and that can be created, managed, and consulted by authorized clinicians and stand across more than one health care organization (Wager, Lee, & Glaser, 2013, p. 136). In other words, EHR are patient’s medical history electronically which can include their past health, social health, demographics, medications, diagnosis, progress notes etc. EHR’s were developed to improve patient care .
I still remember the days before EHR were started. I was working as a Health Unit Coordinator, and was responsible for getting the patient’s charts together and all the required forms that will be used for the patient doing there admission. The charts were broken down upon patient discharge, and sent to medical records. The charts would have to be requested again from medical records in the event that the patient was admitted again at a later date, and the physicians and nurses would have to go through the charts to review the patient’s history. Health Care has come a long way since then. In this paper there will a discussion and examination on the current use of electronic health records and its relationship to health care. All of the providers and nurses that are responsible for the patient’s care, are able to review and share information on the patient. Any nursing care information that is beyond the basic compliance data, is not often included in the data that is being stored though EHR Today, nursing care data, beyond basic compliance data, is very seldom included in this data which is being stored electronically, even though there are studies that showing that including nursing problems will improve the accuracy of healthcare cost and patient outcomes. Welton, Halloran, and Zone-Smith (2006). By
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
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
After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital
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 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
AHIMA. "Assessing and Improving EHR Data Quality (Updated)." Journal of AHIMA 86, no.5 (May 2015): 58-64.
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
A wave of medical errors and patient deaths caused by healthcare providers renewed the search for a viable EHR system in 2000. Electronic health records would allow "providers to make better decisions and provide better
“… longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting”. Included in this information are patient demographics… reports. The EHR automates and streamlines the clinician 's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, and related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting.”(GAO, 2010)
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.
Unfortunately, physician's perceptions are not objective outcome measures (Schenarts and Schenarts, 2012). It’s very dangerous the fact that providers rely on the electronic system to catch our errors. Furthermore, some of the most notable benefits of EHR include providers’ ability to access patients’ medical history almost anywhere, at any time. Nonetheless, the heavy reliance on health information technology is a major concern. It has the potential to cause harm to patients instead of the intended purpose of patient safety. Some examples of this include latent errors that do not manifest until they have already caused harm to the patient, or system failures which can cause a delay in time for healthcare professionals to review records thus, causing a delay in patient care. In addition, patient orders can be lost or miscommunicated. Healthcare providers rely on with confidence that the computer system will seamlessly promote the quality care of patients. According to Fiercehealthcare.com (2017), because of deficiencies in the eclinicalworks software, patients could not rely on the accuracy of their medical records. In addition, one patient was
As stated in the reading on page 15, the use of EHRs for research would allow for measuring the health of certain patient populations and even provide evidence for improving efficiency and effectiveness for healthcare processes and outcomes. Data from EHRs could be collected to improve quality of care to patients by checking for accuracy in the records and also looking through medication and allergy logs to assure that all correct medication was given. EHRs could also be collected to review patient’s demographic information if physicians were noticing a familiarity in the patient’s symptoms, which could allow for quicker control of an outbreak or a contagious
This report outlines how data from EHR can be used towards Meaningful Use (MU), Big Data Analysis, Machine Learning and Advanced Computing for better healthcare decision making process. Will try to understand EHR’s ability to integrate with other systems and tools for data sharing/mining and how this is transforming into better care management. Health Information Technology for Economic and Clinical Health (HITECH) MU EHR incentive program have provided the much needed “push” towards adoption of EHR and resulted into incentivized payment for providers which is contributing towards increased quality, safety and efficiency within health care organizations (HCOs). Future is now revolving around how EHR can contribute towards latest data driven technological advancements in healthcare and contribute towards better care management with reduced cost.