The CCR and CCD Contain Some of the Same Standard Rules Essay

Patients are taking an aggressive role in their healthcare needs. Patients desire to in touch with their medical records. Medical professionals are utilizing the Electronic Health Records to implement current data into information necessary to provide quality care for the patient. Thereby, managing patients’ current, and past histories. To understand what is occurring today, one must recognize why patients are taking an active approach to their healthcare.

The information sharing document is often patient-centered. This means that the patient is in relation to each type of material in rotation. In fact, when a document having the patient’s information is going around in different health information systems, it is vital in guaranteeing that all the systems are referring to the patient in question. Therefore, this type of

One of the most important characteristics of an EHR while storing the clinical information is its ability to be interoperable: to share that information among other authorized users. If different information systems cannot communicate or interact with each other, then sharing is not possible. In order to achieve the objective to exchange clinical

There was a time when office staff had to flip through drug code books, CPT and ICD books. But, with AthenaHealth, drug codes are embedded inside of this EHR from the moment the physician prescribes any medication. Instead of grabbing that large ICD code book, this EHR narrows an ICD-10 code by the diagnosis details. AthenaHealth also embeds clinical guidelines for any specialty guidelines. On an average month, a physician’s office would receive 1,000 faxes but, when you become associated with AthenaHealth all that filing of reports are no longer any worry to you. Why? Because this EHR also has the function of sorting and receiving incoming faxes and places results in the correct patient's’ chart. This saves staff time and can close any loop orders that can intervene in the workflow within the office.AthenaHealth has introduced athenaTEXT for physicians who uses text messaging more than calling, which is very common these days. So, AthenaHealth has enabled HIPPA which can send text, images and medical information with encryption to colleagues without the worry of information being contained from outside sources. The EHR portal is very easy to maneuver which includes the EHR homepage, patient chart, epocrates (helps physicians get right to the point of care), and meaningful use and quality programs. AthenaHealth has created two patient communication systems. One communication system that has been

In this case, CAC technology also provides a connection between EHR documentation and transcription systems. Primarily, CAC technology in a healthcare environment has rapidly and drastically changed the process in which medical coding in health-information management. This is handled for a better productivity and efficient workflow solution, including production monitoring, coding review, management reporting, computerization of coding and auditing. Clinical documentation is ensuring that it has routinely generated medical codes from computer assisted codes (CAC). In addition, CAC technology has enabled healthcare organizations to recognize the revenue-cycle process as they increase their requirements towards improved quality. The complete implementation of the CAC technology is essential when improving the main necessities towards patients, such as the efficiency, quality, productivity, and management of their care. Last but not least, CAC technology has produced one of the best strategies for the challenges that the HIM professionals face as coding becomes one of the most important aspects of transitioning to

It is no secret that the medical profession deals with some of population’s most valuable records; their health information. Not so long ago there was only one method of keeping medical records and this was utilizing paper charts. These charts, although still used in many practices today, have slowly been replaced by a more advanced method; electronic medical records or EMR’s. “The manner in which information is currently employed in healthcare is highly inefficient, which slows down communication and can, as a result, reduce the emergence and

As useful as the EMR is to patient care there exist a few drawbacks when records are transformed from paper into the digital form. Even though patient health records can only be accessed from inside the hospital’s computers, the EMR can be accessed from anywhere inside the hospital or from another hospital or clinic within the same organization. Before the implementation of the EMR, healthcare staff had to go directly to the patient 's physical chart and thumb through pages of information. Now, with the EMR, any hospital employee can access any patient 's information anywhere inside the hospital. EMRs are more easily accessible, even to personnel not involved in the

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

It has only been within the last five years that health information management (HIM) has experienced exponential changes, due to the healthcare reform. The electronic health record (EHR) is connected to health information exchanges and other systems of interoperability. The timely completion of charts, coding and release of information (ROI) has become much more efficient with the electronic record. Traditional HIM functions will just be transformed and will always be an integral part of successful patient care. Professionals must be flexible and willing to adapt and even generate change. As Health Information Technology continues to evolve, so will the roles

“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

Like mentioned above, JCAHO is a nonprofit organization that accredits institutions consistent with requirements and policies they need to abide by. Their mission is, “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (The Joint Commission, 2015) and their vision is “All people always experience the safest, highest quality, best value health care across all settings”. This organization was found in 1951 where they intended to continuously improve health care for the

Health Information Exchange (HIE), which is also known as “Summary of Care”, is an objective that is required for eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs) that are taking part of the Electronic Health Record (EHR) Incentive Program from 2015 until 2017 under Meaningful Use Stage 2 (MU2). The objective contains one required measure for participation in the program. The measure is: certified EHR technology (CEHRT) must be used to create a summary of care record which is to be used transmit care information between entities involved in the care of the patient referred (Services 2016). The items that must be included in the Summary of Care documents, provided the referring provider knows the information, are shown in Table 1 (Mostashari 2012, Services 2016). Currently the standard format that has been adopted for Summary of Care documents follows Consolidated Clinical Document Architecture (C-CDA) guidelines.

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

It is important to exchange health care data because it improves efficiency and decrease cost for health delivery, and worldwide or international standards will make a positive difference in the way we capture and utilize health information around the world. There are quite a few advantages when it comes to exchanging health information or data, however, the value of electronically exchanging is the standardization of data. Once data is standardized, the data transferred can seamlessly integrate into the recipients’ Electronic Record (EHR), further enhancing and boosting patient care.

The HIPAA transactions and code set standards are certain rules that regulate electronic data interchange (EDI) of healthcare information, which include patients’ identifiable and medical data, between two or more parties. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), if providers or healthcare organizations conduct one of the nine types of electronic transactions of health-related information, they must adhere to the standards, which include claims status reporting, claims submission, referral authorization and certification, and benefits coordination. In addition, HIPAA mandates that all transactions must use standardized medical code sets, such as CPT codes, Health Care Procedure Coding System (HCPCS), and ICD-10, to ensure the uniform communications between providers, healthcare organizations, and payers ( American Medical Association, 2013).