Introduction The use of medical records for the purposes of scientific research is not a new methodological concept. Physician Alvan Feinstein and co-authors wrote a series of seminal articles articulating the problems associated with medical record reviews in cancer research in 1969 (Feinstein, Pritchett, & Schimpff, 1969a, 1969b). What has changed, however, is the advent of new technology associated with medical records, most notably the rise and proliferation of the electronic health record (EHR). The capabilities of EHRs to integrate patient, clinical, and system-level data into computer-based systems has led to the use of clinical EHRs for numerous research applications including observational, comparative effectiveness, and …show more content…
For example, Brennan & Watson (2012) found over 1600 adults over the age of 30 miscoded as having attended outpatient child and adolescent psychiatry services in the National Health System EHR database, a likely error in data imputation (Brennan & Watson, 2012). Data abstraction methods that use automated abstraction techniques for EHRs may also have issues related to data accuracy. For example, when compared to manual chart abstraction of EHR data, automated data extraction techniques have variable positive predictive values, some as low as 20% (Kahn et al., 2012; Mullooly, Donahue, DeStefano, Baggs, & Eriksen, 2008).
Complete Data and the Abscense of Evidence Data completeness in EHR data quality represents the overall completeness of the data, also defined as the degree of missing values within the database or dataset (Schafer & Graham, 2002). Data completeness is context driven, meaning not all missing data is missing for the same reason. For example, cosmologist Martin Rees in pondering the abscense of data indicating extraterrestrial life succinctly described the problem as “absence of evidence is not evidence of absence” suggest that evaluation of missing data requires key consideration of missing data context (Oliver, Billingham, Breu, Guggenbichler, &
Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.
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
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
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).
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
In 2004 president George Busch announced the goal to mandate electronic health records for every American by 2014. This would require every paper chart to be converted to electronic chart so that health care providers and the patient themselves can access their information through the internet (Simborg, 2011). The purpose of developing the EHR is to provide appropriate patient information from any location. Also to improve health care quality and the coordination of care among hospital staff. To reduce medical error, cost and advance medical care. Last to ensure patient health information is secure (DeSalvo, 2014) The Department of Health and Human Services appointed the Office of the National Coordinator for Health
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
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
According to The Healthcare Information and Management Systems EHR is considered a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting( Kohli & Tan, 2016). The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) describes EHR as an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that person’s care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports (CMS.gov). The International
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
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
AHIMA. "Assessing and Improving EHR Data Quality (Updated)." Journal of AHIMA 86, no.5 (May 2015): 58-64.
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
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).