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Electronic health record introduction
Electronic health record introduction
Introduction to electronic health records
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“Meaningful Use” implemented in July, 2010, set criteria’s for physicians and hospitals to adhere, in order to qualify for certain financial incentives and to be deemed meaningful users (MU) of the EMR. Meaningful use in healthcare is defined as using certified electronic health record to improve quality, safety, efficiency, and reduce mortality and morbidity. There are 3 stages of meaningful use implementation. The requirements for the 3 stages are spread out over a period of 5 years. MU mandates that physicians meet 15 core objectives and hospitals meet 14 core objectives (Hoffman & Pudgurski, 2011). The goal is to in-cooperate the patient and family in their health, empower autonomy to make decisions while improving care in all population. …show more content…
It is true that all EMR’s may not have the same functionality, but the overall outcome should be the safety and wellbeing of the patient. Standardized billing is an excellent way to make good use of the EMR. The ability to capture revenue in a faster and more concise manner is always a benefit for any healthcare facility. Monies that were once considered lost or “written off” expenses can now be captured due to the EHR.
Portability can improve patient care. Patients no longer have to “tote” their cumbersome medical records around anymore. EHR’s give physicians and clinicians access to critical healthcare information in the palm of their hand, which ultimately leads to improved patient care outcomes. EHR’s also provide security to vital medical and personal healthcare information. Organizations like HIPPA defines policies, procedures and guidelines for preserving the privacy and security of discrete distinguishable health information (HHS.gov,
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The goal of ONC is to guarantee that health care clinicians and hospitals purchase a system that meets certain standards and criteria to perform those tasks. Centers for Medicare and Medicaid Services (CMS), introduce the Medicare and Medicaid EHR Incentive Programs that offers financial incentives to eligible providers, hospitals and critical access facilities. To qualify for these benefits, providers, hospitals and critical access must show “meaning full” use of the EMR (Tripathi, 2012).
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,
The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
Meaningful Use and the EHR Many new technologies are being used in health organizations across the nation, which are being utilized to help improve the quality of health care. Electronic Health Records (EHRs) play a critical role in improving access, quality and efficiency of healthcare ("Electronic health records," 2014). In order to assist in expanding the use of EHR’s, in 2011 the Centers for Medicaid and Medicare Services (CMS), instituted an EHR incentive program called the Meaningful Use Program. This program was instituted to encourage and expand the use of the HER, by providing health professionals and health organizations yearly incentive payments when they demonstrate meaningful use of the EHR ("Medicare and Medicaid," 2014).
With today's use of electronic medical records software, information discussed in confidence with your doctor(s) will be recorded into electronic data files. The obvious concern is the potential for your records to be seen by hundreds of strangers who work in health care, the insurance industry, and a host of businesses associated with medical organizations. Fortunately, this catastrophic scenario will likely be avoided. Congress addressed growing public concern about privacy and security of personal health data, and in 1996 passed “The Health Insurance Portability and Accountability Act” (HIPAA). HIPAA sets the national standard for electronic transfers of health data.
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.
“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.
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
Meaningful Use (MU) is defined as a healthcare provider’s usage of certified EHR technology in a way that can be measured largely in quality and in quantity. By establishing meaningful use using an Office of the National Coordinator (ONC) certified EHR program; healthcare providers can collect stimulus money, as arranged through the HITECH act of 2009. MU is designed to improve healthcare quality, efficiency, safety, and help to reduce health disparities. Also this helps to maintain privacy and security of patient healthcare information. (EHR Incentives & Certification, 2014)
The health industry has existed ever since doctors bartered for chickens to pay for their services. Computers on the other hand, in their modern form have only existed since the 1940s. So when did technology become a part of health care? The first electronic health record(EHR) programs were created in the 1960s around the same time the Kennedy administration started exploring the validity of such products (Neal, 2013). Between the 1960s and the current administration, there were little to no advancements in the area of EHR despite monumental advancements in software and hardware that are available. While some technology more directly related to care, such as digital radiology, have made strides medical record programs and practice management programs have gained little traction. Physicians have not had a reason or need for complicated, expensive health record suites. This all changed with the introduction of the Meaningful Use program introduced in 2011. Meaningful use is designed to encourage and eventually force the usage of EHR programs. In addition, it mandates basic requirements for EHR software manufactures that which have become fragmented in function and form. The result was in 2001 18 percent of offices used EHR as of 2013 78 percent are using EHR (Chun-Ju Hsiao, 2014). Now that you are caught up on some of the technology in health care let us discuss some major topics that have come up due to recent changes. First, what antiquated technologies is health care are still using, what new tech are they exploring, and then what security problems are we opening up and what is this all costing.
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...
As EHRs expand their functionality to include recall and reminder alerts, clinical decision supports, mhealth, and more complex tasks, they are considered comprehensive (Magnuson, 2014). Through this evolution, providers and patients will be able to share access to electronic health information that allows them to collaborate in joint, informed decision making which has the potential to greatly impact patient and population health (Healthit.gov, 2014) as it involves a clinical shift from the treatment of conditions to prevention through behavior and lifestyle modification (Magnuson, 2014). The management of patient collaboration will shift from being primarily the responsibility of the patient to that of accountable organizations. Shahid Shah, an award-winning Government 2.0, health IT, and medical device integration software expert, outlines the five stages of EHR maturity in patient care collaboration
The new healthcare technology that is spreading nationwide it the EHR programs that are being implemented and updated in healthcare organizations. Government policies are in place for societies protection and privacy, it also helps to create a place where healthcare information can be utilized to its fullest potential. ONC authors’ regulations that set the standards and certification criteria EHRs must meet to assure health care professionals and hospitals that the systems they adopt are capable of performing certain functions (HealtIt, 2015).
290). Throughout numerous healthcare organizations, e-Health techniques are regarded as vital to the delivery of quality, patient-centred health care. The e -technology can improve patient-physician relationships, to guide aimed questions for greater understanding of health conditions and better management of the health disorders. As per The Centers for Medicare & Medicaid Services e-Health initiatives will help the health care industry deliver higher quality care and reduce costs. Among the limitations and shortcomings of E-health are the chances of impersonality, e-Health applications might not be user-friendly and commonly available. Patients also need to develop confidence in E-health. Concerns about privacy and security of information have slowed the development of this initiative (McGonigle & Garver Mastrian, 2015, p. 290). It is critical to assure the security of health-related medical records. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the main Federal laws that protects patient’s health information. The Law requires the organizations that manage health information to have policies and safeguards to protect health information saved on paper or
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).
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).