Reference no: EM13830407

Electronic Health Records

Summary

Electronic Health Record was introduced to make it more easily putting information on patients down. EHR has many applications which have various functions including E prescribing.Health Level 7 E.H.R. Systems Functional Model is also available in EHR Systems. It has many benefits such as providing an international standard for global use. Clinical Decision Support is also available and it works to assist physicians, nurses, and other clinicians make decisions about patient care such as:Providing documentation of clinical findings and procedures and suggestions for prescribing. Continuity of Care is another element in HER and it has its standards. Quality Measurement and Reporting is also part of it and CMS provides hospitals who report designated quality measures higher update to their payment rate.

Collecting data has been burden for this type of reporting and so Physician Quality Reporting Initiative (PQRI) came up. Under EHR we also have Document Management Systems which involves imaging and output systems. The following are also enabled under EHR: Electronic signature authentication,digital dictation system and speech recognition, Knowledge databases are also available which provide decision making support systems.Computerized provider order entry systems includes a lot and some of them are: information that pertains to patient and those that are to be used by the administration, there also exchange programs and modes of storage so that the data is not vulnerable to loss or distortion.

Assignment

Electronic health records (EHR) also known as electronic medical report (EMR) has been used to make easier providing information on patients rather than using the manual form, that is paper work.  This method proves good since it is easy to use, it provides a single set of records, and it also provides better collaboration(Rotich, 2003). On the other hand it has its cons since at times security and privacy is not guaranteed, apart from that it also requires training and there is also potential loss of data.

Amongst the barriers of implementation there is always the issue of High capital cost and insufficient return on investment for small practices and safety net providers, underestimation of the organizational capabilities and change management required, failure to redesign clinical process and workflow to incorporate the technology systems, concern that systems will become obsolete, lack of skilled resources for implementation and support, concern that current market systems are potentially not meeting the needs of rural health centers or federally qualified health centers (FQHC) and Concern regarding negative unintended consequences of technology.

These barriers can challenge the implementation at both office and hospital system.

Electronic health records provide medical charts and records on various patients in a hospital setting being taken care of. Initially information on Doctor patient interaction was chiseled on tablets and this was cumbersome, later advancements led to paper which has its disadvantages too and so we are embracing technology and using the electronic system.

Paper work was disadvantageous in the process of storage and retrieval, they could wear and tear, no back up would be provided and they could only be found in one place at a time, they could not give room for research and they were also passive in nature.There are different types of electronic health (EHR) records such as: - EPR - Electronic Patient Record, EMR - Electronic Medical Record, CbPR - Computer-based Patient Record, CPRS - Computer Patient Record System and EHR - Electronic Health Record. The big difference between EPR and EMR is that EPR is more of patient oriented(Hogan, 2007).

The advent of technology has made work easier since information can be retrieved with ease, there are scheduled backups and data can be provided at different levels. There is also varied ways of entering data or input and output systems, data can be related and connected, security, cost saving, improved quality care and it is also cost saving.Electronic health records also have short comings in terms of security and expertise and even ubiquity of access.

These are the components of electronic health records: Integrated view of patient data, Clinician decision support, and Clinical order entry, Access to knowledge resources and Integrated communication support (NCPDP, 2015). I have learnt that these systems provide easy collaboration since data is entered and information is got from one source.Electronic health records are very efficient in use compared to paperwork that is vulnerable to fire and other minor destruction and loss.

Reference.

Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Vu N, et al. (2003). Installing and     Implementing a Computer-Based Patient Record System in Sub-Saharan Africa: The Mosoriot Medical Record System. J Am Med Inform Assoc.

Hogan WR, Wagner MM. (2007). Accuracy of Data in Computer-Based Patient Records. J Am   Med Inform Assoc.

NCPDP. (2015). Standards Information. Retrieved from: https://www.ncpdp.org/Standards Development/Standards-Information

Article summary

Authentication assigns a particular responsibility for a particular task. The organization has a role to play in this case, which involves the consultation of state statutes and regulations in the bid to confirm the exact regulations regarding the authentication of entries. For paper based records, identification of an author is generally related to the inclusion of a recognized signature or initials. In electronic means, this involves the use of digital signatures or in other cases, the use of a computer key. Signatures are basic considering that they are used to authenticate entries in both paper and electronic records. Both paper based and electronic records have significant differences. Paper based record keeping has proven to be highly tedious and more inconvenient as time goes by; the bulkiness in information is what leads to increased elements of inefficiency. Regardless of whether a health record is paper or electronic, there is a need to comply with all set regulations with regards to record keeping, and more so observe total accuracy in medical recording.