The Electronic Health Record

Electronic health records (EHR) are health records that are generated by health care professionals when a patient is seen at a medical facility such as a hospital, mental health clinic, or pharmacy. The EHR contains the same information as paper based medical records like demographics, medical complaints and prescriptions. There are so many more benefits to the EHR than paper based medical records. Accuracy of diagnosis, quality and convenience of patient care, and patient participation are a few examples of the

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

Electronic health records were a technological advancement in the healthcare industry in which paper patient record’s became digital. The transition from paper to digital charting allowed easier, quicker access to patient information for those who were authorized to do so. EHRs are secure and protected with username and password access only. It contains information such as patient medical history, procedures, diagnoses, medications, labs, tests, and treatments. Healthcare professionals and organizations who are authorized to access a patient’s electronic health record can do so at ease via a secure network or online database (HealthIT, 2013).

The purpose of this paper is to discuss the electronic health record mandate. Who started it and when? I will discuss the goals of the mandate. I will discussion will how the Affordable Care Act ties into the mandate of Electronic Health Record. It will describe my own facility’s EHR and what steps are been taken to implement it. I will describe the term “meaningful use,” and it will discuss possible threats to patient confidentiality and the what’s being done by my facility to prevent Health Information and Portability Accountability Act or HIPAA violations.

Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.

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.

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.

Electronic Health Records (EHRs) is another version of a patient’s medical history, that is maintained by the healthcare facilities or provider over time, and may include all of the key administrative clinical data relevant to that persons care under particular healthcare facilities, including demographics, progress notes, medication, x-rays, surgical history, and etc.(CMS,2012). While the adoption of the electronic health record system seems promising for the healthcare community and having a positive impact on the HIM field with better care and decreased in healthcare cost, and other promising aspects. However, poor EHR system design and improper use can cause EHR-related errors put at risk to honesty of the information in the EHR; causing or leading healthcare facilities and hospital to break that confidential bond they have with the patient. This will cause EHRS to have errors that endanger patient safety or decrease the quality of care that the patients expect from the hospital or healthcare facility (Bowman, 2013). In the paper I will discussed the topics along the lines like managing the Transition from Paper to EHRs, EHRs to redefine the role of doctors, and other ways how EHRs impact will have on the HIM community.

An Electronic Health Record (EHR) is an electronic version of a patient medical history that is maintained by the provider over time (CMS.gov, 2012). They are patient-centered records making the information available instantly and secured. It can include all of the key administrative clinical data relevant to the patients care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunization, laboratory data and radiology reports. EHRs are able to be shared and manage information across multiple providers, labs specialist, imaging facilities and organization through health information exchange.

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Electronic health records, like electronic medical records, contain detailed information about a patient’s health status, but they also provide a larger view of the patient’s care. They are records intended to be

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

A medical health record or electronic health record is mostly used by providers for diagnosis and treatment. A EMR is “an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization” (NAHIT 2008, 6) {-Page 3 in textbook} The Hybrid record refers to a record that contains both paper and electronic information that is transferring information from the paper record and the electronic record but are still being used at the same time. This record is “composed of electronic stored information from numerous clinical information systems, such as laboratory, pharmacy, radiology, nursing, and other ancillary or administrative systems. {Page3} However, the paper record has been used for decades but now organizations are transferring to hybrid or electronic records. The paper health record will be taken over by the electronic record in the future because of its convenience. This brings us to the observation of the personal health record which is defined as an electronic record that contain health related information on a person or individual that conforms to nationally recognized multiple sources

Implementation of the electronic health records (EHRs) has been a growing trend in the healthcare field from fear of the unknown to the acceptance of the reality of the EHRs and the actually utilizing the system. The struggle to go live with the EHR was a challenge because change is always a difficult implementation. According to Fickenscher & Bakerman, (2011) Change is a process that is individualized base on one's ability to adopt and the interest on the change. Some people may take longer to understand a process while others will grab the skill within a short time. However, some few setbacks slow down the adoption of the EHRs when it was first implemented, Culture, communication and training and time. Despite

Electronic health records (EHRs) are essential to improving patient safety. An electronic health record is an electronic version of a patient’s medical history typed and stored on a computer or some electronic database. It would include general information about the person in question (e.g:age,gender,weight,height.), information about the patient with regards any current or previous medical conditions, allergies, treatments, medications, prescriptions, immunizations, x-ray/lab reports and any general doctor’s/nurse’s notes and reports on previous assessments throughout the patient’s lifetime. (Cms.gov, 2016.) Health records contain such a vast amount of information about a person and it is believed storing them in electronic