JOURNAL
B.rasika T.nandhini From 2nd bsc.cs
Hospital Medical Record Digitisation -----------------------------------------------
ABSTRACT
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An electronic health record (EHR), or electronic medical record (EMR), refers to the systematized collection of patient and population electronically-stored health information in a digital format. It details medical problems, medications, vital signs, patient history, immunizations, laboratory data and radiology reports, progress notes .These records can be shared across different health care settings. It resides on an enterprise information systems and is exchanged via electronic networks.EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.why is it needed? It seeks to be a complete record of a patient that can follow him/her from setting to setting increasing knowledge and consistency. It allows providers to obtain a complete picture of a patient and allows firms to automate and streamline workflows. It could improve patient and financial outcomes via evidence-based decisions, quality management, data mining, tracking, and reporting.
INTRODUCTION:
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“An Electronic Health Record (EHR) is 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
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connecting to the system and internet can be more difficult for system that is located in a rural seting over an urban region. Mark certain the location of your practice will make EHR implemenatation and usage a non stressful task for
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Did you ever think about how much time is spent on computers and the internet? It is estimated that the average adult will spend over five hours per day online or with digital media according to Emarketer.com. This is a significant amount; taking into consideration the internet has not always been this easily accessible. The world that we live in is slowly or quickly however you look at it: becoming technology based and it is shifting the way we live. With each day more and more people use social media, shop online, run businesses, take online classes, play games, the list is endless. The internet serves billions of people daily and it doesn’t stop there. Without technology and the internet, there would be no electronic health record. Therefore, is it important for hospitals and other institutions to adopt the electronic health record (EHR) system? Whichever happens, there are many debates about EHR’s and their purpose, and this paper is going to explain both the benefits and disadvantages of the EHR. Global users of the internet can then decide whether the EHR is beneficial or detrimental to our ever changing healthcare system and technology based living.
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
IT problems are not only a hassle, they can seriously affect your practice’s productivity and patient satisfaction. EHR hardware and software problems force staff to work longer hours to play catch-up.
Electronic health records (EHRs) Has improved the quality and safety of patient care and achieve real efficiencies in the healthcare delivery system throughout the years. EHRs are the tools through which physicians, nurses, and other staff enter, view, and share the information required to deliver high quality care. it is vital in clinical decision making for patients and physician; therefore, the U.S. Department of Health and Human Services provides Healthcare industries with The Research-Based Web Design and Usability Guidelines. In the user-interface (UI) design community this is partially addressed through the establishment of interactive patterns and collection of building blocks that represent recurring solutions to common design problems.
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
EMRs provide a common access point where clinicians and health care providers can review and document information about clients and their care. These records are essential to improving efficiency and increasing client safety (Electronic Medical Records, n.d.). Electronic reports are an enabling technology that allows medical practices to pursue more powerful quality improvement programs than is possible with paper-based records (Miller, Robert; Sim, Ida). Clinicians and clients do not have to worry about errors occurring due to the poor legibility of handwritten paper medical records. EMRs facilitate the continuity of care before, during and after hospitalization because all the data in one place. Think of the amount of time and money employees spend on phone calls, emails, and faxes ...
Over the years, healthcare facilities have acted like a storehouse for patients’ medical records, uninterested and unable to distribute clinical data to anyone beyond their organization. The EHR, started in the 1960s under the name of "computerized-based patient record" (CPR), became known as "electronic medical records" (EMR) in the 1990s and today it is known as electronic health record (EHR).The target of the Department of Health and Human Services (HHS) is to incorporate the EHR and use it in a "meaningful" way to improve the quality, efficiency, and safety of patient care delivery; to engage patients in their personal health record; and to improve care coordination. Equally important, the "meaningful use" of the EHR system intends to build a bridge to other systems by creating an interoperability of health information while implementing quality care throughout. However, this interoperability can only be accomplished when the receiving system and the user fully understand how to apply these exchanges.
The EHR is a computerized health record that will take place of the paper chart. The health care information will be available to all health care providers at anytime, anywhere. The record will contain medical history, diagnosis, medications, immunization, allergies, diagnostics and lab results; from past doctors, emergency department visits, school, pharmacies, and out patient laboratories and facilities (Department of health and human services, 2014). Health care providers will be able to access evidence-based tools to aid in decision-making. EHR will also streamline workflow, and support changes in payer requirements and consumer expectations. In 2004, “the HHS secretary, Tommy Thompson appointed David Brailer as the national health information coordinator to provide: leadership for the development and nationwide implementation of a interoperable HIT infrastructure, with the goal of establishing electronic health records...
An Electronic Health Record is defined by NEHTA Acronyms, Abbreviations & Glossary of Terms (p22, 2005) as “an electronic longitudinal collection of personal health information, usually based on the individual, entered or accepted by healthcare providers, which can be distributed over a number of sites or aggregated at a particular source. The information is organized primarily to support continuing, efficient and quality health care. The record is under control of the consumer and is stored and transmitted securely”
RESULTS Positive Impact: 1. Enhanced positive health results (Mastermind, 2015): Earlier, when the healthcare system relied on the paper based medical records, the medical professionals had to request the other physicians in order to get the medical history of the patient. The physician had to wait un till the he received the patient’s medical information which in turn delayed the care. With the advent of the electronic health records, the physician can easily access to the patient’s previous health information and provide the care immediately which also eradicates the occurrence of the errors.
The implementation of electronic health records (EHR) continues to make an impact on nursing and patient care throughout the country. As a part of the American Recovery and Reinvestment Act of 2009, all public and private healthcare providers were required to implement electronic health records in their facilities by January 1, 2014. By demonstrating “meaningful use” of the electronic medical record, facilities are able to maintain Medicaid and Medicare reimbursement levels. Providers who show that they are meeting the “meaningful use” criteria during EHR use will receive an incentive payment from Medicare and Medicaid. “Meaningful use” is “using certified technology in EHR implementation to improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination; and maintain privacy and security of patient health information” (Centers for Medicare & Medicaid Services, 2013).
As life progresses digitally, people have become reliant on the ability of having access to endless amounts of information at the tips of their fingers, including health records. With the increasing demand for digital life, medical facilities are shying further away from physical paper records and documentation. Electronic health records (EHR) provide the function for all of a patient's past and present medical history to be compacted into one personalized digital profile, which can be used interchangeably throughout all medical facilities that one attends. The internet provides people with numerous ways to look into health care, whether that is thorough websites that diagnose, claiming to have all the answers, or simply downloadable health
Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely provide better preventive care than were healthcare professionals who did not. (page 116). From 2004, EHR has initiated, even the major priority of President Obama’s agenda is EHR (Madison & Stagger, 2011). Health care administration considers EHR as the introduction of advanced technology which can improve patient satisfaction are can increase the financial incentives of the healthcare organization. Studies have pointed out that the federal policy is proposed to transform all medical records into EHR (Hebda & Calderone, 2010).