Electronic Medical Record Systems : Supporting Better Health Through Technology

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.

Although handwritten records are still the mainstay of clinical record keeping, many medical professionals believe that the increased use of information technologies has the potential to effect healthcare for the better. For example, Dr. Daniel R. Masys said, “Against a background of an explosively growing body of knowledge in the health sciences, current models of clinical decision making by autonomous practitioners, relying upon their memory and personal experience, will be inadequate for effective twenty-first-century health care delivery.” While keeping in mind how far manual records have gotten us, we need to realize that information technologies result in better data correlation and management.

The Role of Electronic Health Records and Health Information Exchange in the Delivery of Quality Healthcare

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

The Inner City Clinic is experiencing problems with medication prescribing errors and seeks a resolution to this problem through use of electronic medical records and registration medication reconciliation. The Institute of Medicine reports in the work entitled "Preventing Medication Errors" that the "average hospitalized patient is subject to at least one medication per day. This is reported to confirm previous research findings that medication errors represent the "most common patient safety error." (Barnsteiner, nd, p.1) Medication reconciliation is described as follows:

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.

For a nation to be technologically advanced, the United States (U.S.) is having a hard time overcoming the dark era of utilizing hand written scripts, progress notes, and paper records. In comparison to other countries, the U.S. is lagging behind in the health care system. Even with all the improvements that have been made recently, the U.S. ranked last in 2014 in areas such as access, efficiency and equity compared to Australia, Canada, France Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom (Davis, Stremikis, Squires, & Schoen, 2014). Now, as our nation is trying to improve the quality, access, and proficiency of our health care, concerns have been raised whether the new policies are adequate enough for privacy amongst sharing and obtaining health information. This paper was put together to give background information on how the electronic medical record came about and whether privacy is a major concern amongst the American population.

Healthcare is a complex entity that encompasses a variety of specialties necessary toward meeting the needs of patient seeking clinical services. There are multiple communications necessary to efficiently meet patient needs. For many years detailed documentation, progress notes, specialty consults, and physician orders have been hand written. The legibility of this documentation was often illegible, and difficult to decipher, which resulted in clarification orders and often delays. The electronic medical record was introduced approximately 50 years ago with an ultimate goal of compiling healthcare information for immediate and future reference (Keller, 2016). Since the electronic medical records was initially implemented multiple versions have since been created. Successfully implementing the electronic medical record, requires a great deal of research to ensure that the specifications align with the organization’s short and long term goals.

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 medical record (EMR) is the replacement of paper manual charts and is being used all across the country. As per Hebda and Czar (2013), the EMR is the “building block” of the electronic health record (EHR), which can be defined as “a longitudinal record that includes client data, demographics, clinician notes, medications, diagnostic findings, and other essential healthcare information” (p.293). The widespread use of EHR’s in America is foreseeable and inevitably unavoidable, but by no means a simple and undoubtedly an effortless task to achieve.

The HER automates access to information and has the potential to streamline the clinician’s workflow. In the 1960’s, a doctor named Lawrence L. Weed was the first to break the concept for electronic health records. Weed described a system to automate and reorganize to improve patient records to their use and thus contributing to improving the patient care. Weed’s work formed the basis of the PROMIS project at the University of Vermont which began in 1967 to develop EHR.

The major change from traditional systems to electronic record systems in the healthcare field within the last couple decades has made a huge impact. Patient records, risk management, planning, staff, and more in the organization are affected by the IT staff. “The penetration of Internet access, mobile technologies and social networks collectively offer a future in which it is possible to deliver highly personalized care without necessarily having to do it in person, or even with a doctor.”(Healthcare IT News, n.d.) Many hospitals use paper records for patients long after electronic record technology was available. According to forbes.com in an article published two years ago, less than 2 percent of all healthcare organizations within the United States had and properly deployed information systems.

Achievements in public health and technology have created growth in the health care industry. Significant advances in prevention as well as declines in death rates have created a need for a more sophisticated system of record keeping. While monitoring the health of the nation, planning and developing better health services, and delivering effective and efficient care is now more important than ever. The need to manage patient data has increased as well. Moving from a world where paper records are kept in file cabinets, to implementing a system where documents are stored and maintained on computers and accessed through EMR systems is a complicated procedure for a large system, let alone the smaller independent practices that still

Every day, there are multiple new inventions that are created. These creations range from new electronic devices, new automobiles, new surgical tactics, and even new ways of designing the structure, or framework, of academic buildings. Many professional disciplines bring into existence exciting breakthroughs and technological advances. These developments are vital for society in order to keep up with the fast-moving pace of the world. Perhaps, one of the most important successes of the past few decades has been the creation of Electronic Medical Records (EMR’s). According to the National Alliance for Health Information Technology, the formal definition of an Electronic Medical Record is as follows: “An electronic record of health-related information

As the healthcare landscape continues to shift and evolve, public health departments find themselves facing numerous complex challenges. This makes it imperative that local health departments and individual providers work together to improve the health of their communities.