Health Records And Changing Health Care Delivery Systems

In a healthcare world that operates on stringent budgets and margins, we begin to see the need for a higher capacity healthcare delivery system. This in turn puts pressure on the healthcare organizations to ensure higher standards of patient care, and compliance with the reform provisions. However, these are the harsh realities of today’s healthcare environment, a setting in which value does not always equal quality. The use of technology can help to amend some of this by providing higher capacity care without compromising quality; this can be done with the use of such technology as electronic health records (EHRs). This paper will aim to address how EHRs influence healthcare today by expanding upon topics such as funding sources, reimbursement methods, economic factors, socioeconomic factors, business influences, and cost containment.

The purpose of this discussion board is to describe the Electronic Health Record (EHR), the six steps of an EHR and how my facility implements them, describe “meaningful use” and how my facility status is in obtaining it, and to further discuss the EHR’s and patient confidentiality.

A personal health record (PHR) is an emerging health information technology that patients may use to participate in their own health care and improve the quality and efficiency of that care. Most articles written about PHRs have been published since 2000.

Paper-based health records have existed since the time of Hippocrates. The most significant change in paper-based health records occurred in the 20th century with the development of electronic health records (EHRs), due to evolution of technology (Rocha & Rocha, 2014). The development of EHRs began in the mid-1960s. Since that time, EHRs have continued to advance. Many institutions are now placing a greater effort in the utilization of this advancing technology (Atherton, 2011). The main purpose of EHRs is to increase efficiency of care and organize and improve quality of data storage through new resources and applications (Rocha & Rocha, 2014). EHRs play a vital role in the healthcare system, patient care, and

Electronic health records are helpful to physicians and healthcare providers, because they can be used between different health facilities and agencies. The Electronic Health Record system can be used to improve the effectiveness, quality care, and reduce cost in the future. This record of information contains the history of the patient’s visits to a healthcare facility along with all documentation regarding contact information, patient histories and allergies. The record also contains a list of medications, billing information, and data pertaining to the patient’s visit. The computerized physician order entry (CPOE) allows the physician to electronically enter patient’s orders and view a patient’s lab or x-ray results. It can help detect adverse effects or medical errors and reduce less suffering of the patient if he/she were to receive the wrong medications.

In the modern world technology is everywhere and it affects everyone’s daily life. People are constantly attached to cell phones, laptops, and other electronics, which all have affected how people live their lives. Technology is also a large part of the healthcare system today. There are many electronics and technologies that are used in health care, such as electronic health record, medication bar code scanning, electronic documentation, telenursing, and there are many more forms of technology that impact nursing. One technology that stands out is the electronic health record. The electronic health record, also referred to as EHR, is an electronic version of a patient’s chart, and it contains is a list of the patient’s current medications, allergies, laboratory results, diagnoses, immunization dates, images, treatments, and medical history (“Learn EHR Basics,” 2014). The purpose of the electronic health record is to have a patient’s health care record available to health care providers nationwide, but the patient can decide who has access to their record (Edwards, Chiweda, Oyinka, McKay, & Wiles, 2011). The electronic health record is a very important technology in health care and it impacts nurses, nursing care, and has a significant impact on patient outcomes.

The federal government established a nationwide health information technology (HIT) infrastructure which requires all health care facility personnel to use an electronic health record (EHR). According to Sewell & Thede, in 2004, President Bush called for adoption of interoperable electronic health records for most Americans by 2014. Electronic health records (EHR) is an automated system created by healthcare providers or organizations, such as a hospital in documenting patient care. In addition, EHR is an interoperable healthcare record that can comprise of multiple EMRs data and the personal health record (PHR). Furthermore, electronic health records can be created, managed, and accessed by approved clinicians and staff across more than one health care society (Sewell & Thede, 2013, p. 231-232). On the patients’ perspective, EHR will be used to support healthcare by providing electronic record of patients’ vital signs, demographics, allergies, medications, diagnoses, and smoking status. Consequently, on the providers’ perspective, EHR will support healthcare by use of decision support tools, enter clinical orders, such as prescriptions, provide patients with electronic versions of their health information, use systems that protect the privacy and security of HER patient data. Another meaningful use of EHR is to support activities such as conducting drug formulary checks, including clinical laboratory test results, recording advance directions for patient 65 years and

We live in a world filled with technology. School teachers and college professors use technology to give lectures, health care professionals use technology to keep medical records, or monitor patient’s vital signs, we use technology such as social media, to connect with people and gain acceptance. In 2014, Gary Turk posted a video to Youtube titled Look Up, in which he argues that technology, such as smartphones, causes us to miss out on certain things in life, because we don’t use it in moderation. Technology benefits our lives by making us more efficient in our professional and personal activities.

The purpose of this policy is to establish a record management plan, including the retention and destruction of health records in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA), Public Hospitals Act (PHA) and the Personal Health Information Protection Act (PHIPA). Not only does it serve to identify records which must be maintained, but also specifies how long records must be retained and identifies the appropriate disposal process.

In July of 2004, Tommy Thompson, U.S. Department of Health and Human Services Secretary, stated, "[A]merica needs to move much faster to adopt information technology in our health care system...electronic health information will provide a quantum leap in patient power, doctor power, and effective health care. We can 't wait any longer...” (hhs.gov). In the 12 years since Thompson’s statement, healthcare has been transformed by the beneficial adoption of electronic medical records (EMR) creating savings for healthcare organizations and reducing costs for practitioners and informaticists, as well as other professionals involved in the process.

The Electronic Health Record (EHR) is a vital tool in accessing the important details of the patient, the basic identification such as full name and birthday, the baseline vital signs and the past medical history as well as the current medical or surgical information. The integration of the EHR according to “the Agency for healthcare Research and Quality (AHRQ) study highlighted the overall economic value” as well of having an EHR (McGonigle & Mastrian, 2015, p. 255). The American Nurses Association (ANA) emphasized its goal of nursing informatics, which is to “improve the health of populations, communities, families, and individuals by optimizing information management and communication” in delivering excellent patient care utilizing the

Something to question is new electronic health records helping staff take care of patients or is it a burden. Nursing documentation is always necessary because it provides a reflection of what nurses do for their patients. Documentation helps ensures a flow with patient’s treatment team (Linton & Moon). When documentation is not done correctly or efficiently due to the new technologies it can place the patient at increased risk and added cost to the hospital. Many nurses feel too much time is spent on electronic documentation and not the patient. Nurses know that failure to document is hard to defend in court (Morales, 2014). Having standardized documentation in place can dramatically ensure that patients are getting taken care of, and not have to worry about missing or forgotten documentation and potentially finding health trends in the documentations (“The importance”, 2015). New documentation requirements are effecting nurses in a good way to make sure their care that they provide is being reflected on and noticed.

Implementation of electronic health records and constant change in the health care delivery system has altered the nature of work in Health Information Services (HIS) Departments. Health information professionals are exhorted to work harder and to work smarter (Cassidya 2011,10; Cassidya 2011, 10).

This article notes that as tasks are continually being added and changes within today’s health information services departments (HIS), health information management must compare current practice with organizational goals to determine if work flows must be changed (Layman, E., 2016). As most new tasks start out not as new jobs, but rather enrichment or enlargement of other jobs, managers must look for indicators that these additions are not causing negative consequences (Layman, E., 2016). While job enrichment can be cause for many positive outcomes, negative results can signal a need for redesign of the work process.

(a) Patient’s not wanting to change from paper to electronic records, they want to stick with what they already know, (b)Patients and staff having negative feelings to the portable records without even trying them, (c) Communication issues may arise between staff and the mediator, (d) and staff may have difficulty with patient education because not all patients know how to work with electronics.