Discussion A
Describe the difference between EMR and Clinical Information Systems (CIS). What are the advantages and disadvantages of CIS’s?
EMR is an electronic record of patient health information that is created by each encounter in any healthcare setting (Menachemi & Collum, 2011). Information in the EMR includes patient progress notes, medications, problems, vital signs, immunizations, laboratory and radiology reports and past medical history (Menachemi & Collum, 2011). EMR is used to organize and manage relevant patient, pharmacy financial, radiological and laboratory information (Burke & Weill, 2009). The CIS is a system based on technology that is applied at the point of care and developed to preserve the acquisition and processing of information (McGonigle & Mastrian, 2012).
Advantages of CIS includes efficient access of patient data at the point of care, information that is easy to access due to being legible and structured, better patient safety, through the identification of adverse drug reactions and high risk patients (McGonigle & Mastrian, 2012). Disadvantages include the implementation of CIS is both costly in money and employee productivity, while implementation and development is in progress (McGonigle & Mastrian, 2012). Additional disadvantages may be privacy and security and resistance from staff to learning
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For example, implementation of EMR has been shown to have increased the rate of vaccinations in some hospitals (Menachemi & Collum, 2011). Also, a lower compliance rate with core measures would be a risk to not implementing EMR. The EMR signals a message to physicians to verify that measures are being met. Physicians would not receive these reminders in a paper chart and if they did it would be a very time consuming task for someone to
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
To be considered meaningful users of the EMR, the qualified applicant must use clinical content that is consistent and standardized across systems and healthcare settings, use decision support tools such as alerts and reminders, have the ability to collect and store raw data from documentation that can be used for reporting purposes, collect and report data to the state. Reporting of data will help to improve public health and awareness and provide sharing of information between systems (Tripathi,
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.
The purpose of this paper is to discuss how Electronic Medical Records (EMR), affects healthcare delivery. I will discuss the positives and negatives this issue has on healthcare and how it effects the cost and quality for healthcare services. In addition, I will identify any potential trade-offs to cost or quality. Lastly, I will discuss how the EMR affects my job as well as any challenges or opportunities this issue presents.
Health care information system (HCIS) is an arrangement of information (data), processes, people, and information technology that interact to collect, process, store, and provide as output the information needed to support the health care organization (Wager, Lee, Glaser, 2013, p. 105). Having ready access to timely, complete, accurate, legible, and relevant information is critical to health care organizations, providers, and the patients they serve (Wagerm Lee, & Glaser, 2013). In the health care industry, the quality of care is one of the most important objectives for most health care organizations. The growing developments in health information technology have a great impact on the delivery of health care and have changed the systems used to record and share information. It has the potential to improve the quality of care if it is appropriately used. Health care organizations routinely apply computers and other technologies to record and transfer health information such as diagnoses, prescriptions, and insurance information.
“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 incentive, the government began issuing payments to those providers who “meaningfully use certified electronic health record (EHR) technology.” (hhs.gov) There are three stages that providers must progress through in order to receive theses financial incentives. Stage one is the initial stage and is met with the creation and implementation of the HER in the business. Stage two “increases health information exchange between providers.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) Stage three will be the continuation and expansion of the “meaningful use objectives.” ("United States Department of Health and Human Services | HHS.gov", n.d., p. 1) The hospital, where I work, initiated the HER mandate many years ago. In this paper, I will discuss the progression and the challenges that my hospital encountered while implementing the EHR mandate.
Healthcare professionals associated with medical billing and coding know the progress the technology has made so far. In the last few decades, medical billing and coding has switched from being a paper-based system to a computerized format. Under HIPAA laws, medical practitioners had to develop new software in order to send out electronic bills. With the advent of electronic medical records (EMR), with one touch of a button, doctors, Nurse Practitioners and PAs can gain access to all the care a patient has ever received from every healthcare facility the patients visited previously and can figure out possible illnesses. This enables statistical documentation of the population as a whole as well. EMR can also make the healthcare system more transparent and allow integration with reimbursement data. As the healthcare system changes, this will prevent unnecessary costs and make it easier to get the reimbursements needed to treat a patient.
Wright, A., Henkin, S., Feblowitz, J., McCoy, A., Bates, D., & Sittig, D. (2013). Early results of the meaningful use program for electronic health records. New England Journal of Medicine, 368(8), 779-780. http://dx.doi.org/doi: 10.1056/NEJMc1213481
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 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.
Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
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/
Information and Communication Technology (ICT) has been shown to be increasingly important in the education or training and professional practice of healthcare. This paper discusses the impacts of using ICT in Healthcare and its administration. Health Information technology has availed better access to information, improved communication amongst physicians, clinicians, pharmacists and other healthcare workers facilitating continuing professional development for healthcare professionals, patients and the community as a whole. This paper takes a look at the roles, benefits of Information and Communication Technology (ICT) in healthcare services and goes on to outline the ICT proceeds/equipment used in the health sector such as the