An Introduction in to the World of Electronic Health Records
It is astonishing to see how technology has grown over the years. From computers to cell phones and from film cameras to digital, the world of technology is improving every day. After many decades of growing, there is now a digital system where patients can keep track of their health records and hospitals can view them within minutes. Electronic Health Records (EHR) are digital patient records that keep any provider up-to-date on patient whereabouts to improve quality, prevent medical errors and more (Staff of Medicare.gov, 2017). Before there were Electronic Health Records, patient records were in paper format. Paper records were not as beneficial which is why majority of hospitals
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Information is now managed electronically and another advantage is that medical records are now easily legible. While doctors have been known to have illegible handwriting, computers have proven to be the best way to visibly get a message across and can be efficient when in a time crunch.
Data Specifications
Electronic Health Records are composed of patient information. The authors of Benefits of EHRs explains that Electronic Health Records compute their information rather than just obtaining it (Staff at HealthIT, 2014). This means the records take the data and make it beneficial to the physician by calculating specific details to hopefully prevent error. For example, patients with life-threatening allergies don’t have to stress about telling their health care provider their issues because once the provider accesses the EHR, the records will make it known to the provider immediately about the allergies the patient may have. This is very helpful if the patient is unable to tell the doctor due to unconsciousness or any other ailment. As a personal example, I took a family member
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Physicians use EHR to retrieve patient information and patients use the system simply by requesting and holding the information. In an article entitled, HIMSS: Training Key EHR Implementation Concerns, the authors explain an important piece of information regarding training their workers to implement Electronic Health Records. They state, “One method for ensuring a training program is effective and builds confidence within an organization is to engage end users, those using the system on a day-to-day basis, in the development of the curriculum.” (Staff at Medical Economics, 2013). When people implement this Health Information Technology system, it is important that they are engaged and made aware of everyone that may be affected. There are many ways EHR will benefit the end user. One of the reasons is it provides information efficiently and effectively. It also produces accurate information to benefit both the patients and physicians. Lastly, it makes information more accessible and easily
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
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.
Electronic Health Record (EHR) is a digital collection of patient health information instead of paper chart that captures data at the point of collection, supports clinical decision-making and integrates data from multiple sources in any care delivery settings. The health record includes patient’s demographics, progress notes, past medical history, vital signs, medications, immunizations, laboratory data and radiology reports. National Alliance for the Health Information Technology defines EHR as, “ an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more
This article addresses major aspects such as clinical trial, integrated decision support and guidance, inadequacy of paper record, and data entry. The reason that paper records are not a match for modern medicine is that they are not accessible buy multiple health professionals causing a delay in response to health care, confidentiality and security is a risk granted that anyone could physically change the record and it would become official. The author of this article predicted the basic electronic medical record features that are available today, back in 1999 and the features include integrated clinical workstations with the computational power that can assist with clinical matters, financial and administrative topics, research, and scholarly information. This report indicates that having electronic records can provide efficiency throughout the system of health care for instance the example presented in this article was the process of admission, discharge and transfer of a patient can be changed drastically due to it initially taking hours to going from in and out in minutes. This article will provide the foundation of EMR’s and how time for reform had come more than a decade ago and it’s time for reform once again. With the examples and strategic tactics provided, it is fairly simple to display the evolution of Electronic medical records from
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.
Tan & Payton (2010) describe the electronic health record (EHR), which dates back to the 1950s. These computer-based patient records have evolved into complex systems with many capabilities. They were designed to provide healthcare professionals with a comprehensive picture of a patient’s health status at any time and are meant to automate and streamline the workflow of the healthcare professional (Tan & Payton,
Advances in technology have influences our society at home, work and in our health care. It all started with online banking, atm cards, and availability of children’s grades online, and buying tickets for social outings. There was nothing electronic about going the doctor’s office. Health care cost has been rising and medical errors resulting in loss of life cried for change. As technologies advanced, the process to reduce medical errors and protect important health care information was evolving. In January 2004, President Bush announced in the State of the Union address the plan to launch an electronic health record (EHR) within the next ten years (American Healthtech, 2012).
Electronic Health Records (EHRs) have drastically changed health care. From quality to efficiency, EHRs have transformed Health Care from an inaccurate, inefficient, and problematic system to a system that is much more reliable. Electronic Health Records do have their drawbacks; however, they are much more reliable than a paper system. Through the Affordable Care Act the government is now requiring EHRs to be implemented to receive benefits. Not only that, but the clinic will receive benefits per physician for implementing earlier than other clinics. Meaningful Use may be coming to an end, but many clinics have already implemented a system, which will carry on the policy for years to come. Two main jobs have been created from this: Health Informaticians
Over the last several years, electronic medical records are becoming more prominent in health care facilities, replacing traditional written records. As many electronics are becoming more prevalent with the invention of numerous smartphones and tablet devices, it seems that making medical records available electronically would be appropriate for the evolving times. Even though they have been in use to some extent for many years, the “Health Information Technology for Economic and Clinical Health section of the American Recovery and Reinvestment Act has brought paperless documentation into the spotlight” (Eisenberg, 2010, p. 8). The systems of electronic medical records mainly consist of clinical note taking, prescription and medication documentation,
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
According to Shi & Singh (2015), medical information systems have been available since the 1950s. The proficiency of the IT system has led health care organizations (HCOs) to change and restructure their operational systems. The development and progression of new IT software is a multi-dimensional system, which incorporates the electronic health records (EHR). Electronic health records (EMRs) are clinical communication systems that are used to safeguard the patients’ medical history while building effective measures toward improving the delivery of quality care. I would like to know exactly how the electronic medical records (EMRs) system would improve the quality and delivery of health care services.
Electronic health records (EHR) is defined as the electronic storage of patient’s clinical health information that includes all patient’s relevant health information such as laboratory results, diagnostic tests, medical histories, medications, allergies, etc. (CMS, 2012). Keeping medical information electronically is vital with the goal of providing patients with exceptional quality care and improved patient’s health outcome.
Electronic medical records are a digital version of a paper chart that includes a patient’s medical history from one practice. Most health clinics use electronic medical records for diagnosis and treatment for patients. Electronic medical records come with several benefits compared to paper charts. Electronic medical records allow physicians to track, identify, monitor, and improve a patient’s health quality. Physicians will be able to track a patient’s data over time.
Ragavan, V. (2012, August 27). Medical Records Pals Malaysia : 17 Posibble Reasons How Electronic Medical Records (EMR) Might Support Day-to-Day Patient Care. Retrieved from Medical Records Pals Malaysia: http://mrpalsmy.wordpress.com/category/emr/