In the United States, medical errors are the third-leading cause of death, Schiza, E. C., Neokleous, K. C., Petkov, N., & Schizas, C. N. (2015). Through the proper organization of medical data, efficiency in the exchange of information between providers and real-time access, safety can be improved and lives saved. As with any new process, there needs to be assessment and education before implementing transitions from paper to electronic documentation. There needs to be infrastructure and resources to support this change.
Define electronic health record.
Medical Record is a single record which contains all the individual health data from birth to death. It would include birth records, immunization records, and records of all encounters of illnesses and treatments within a facility, Amarasiri, H., & Dorabawila, S. (2017). Medical records (MR) are also referred to as health records in some countries.
An electronic health record (EHR) is a collection individual’s medical information, Stacy, R. N. (2013, The Electronic health record contains information regarding diagnoses, records of treatment, and medication information, Stacy, R. N. (2013). It creates an overview of an individuals and serves as a vital tool to communicate the information regarding the health of people. EHR contains demographics, statistics, and health-related instruments, Cowie, M. R., Blomster, J. I., Curtis, L. H., Duclaux, S., Ford, I., Fritz, F., & … Zalewski, A. (2017). An Electronic Medical Record is usually created in one place hospital and only focuses on a specific problem and its treatment. It is data obtain during a visit and contains medical, imaging and clinical data. It improves coordination and the continuum of the plan of care for patients Kohli, R., & Tan, S. S. (2016). EHR can help improve the quality of care and aid in cost containment. Patient EHR is also referred as an electronic medical record for storage. An Electronic health record requires proper processes to support it. It is essential for the implementation success as hospitals may invest in complicated and expensive technologies that create more waste in a system already fraught with inefficiency, Kohli, R., & Tan, S. S. (2016).
Compare and contrast the similarities and differences between the electronic health record and the paper record.
There are significant differences between paper and electronic health records. Some are differences inability to secure health information, amount of manual labor required to maintain records, space requirements for storage, ability to read and understand information at a later date, and preservation of records. Paper records need to be file chronologically and store. EHR has multiple benefits as patient data is available can be accessed from anywhere, and the physicians signature is electronic Improving efficiencies. Physician order sets improve care management. The Health Insurance Portability and Accountability Act(HIPPA) was a crucial factor which protects the confidentiality of patients electronic health record. Electronic records helps to standardize formats
Paper health documents must be stored in an area that is secure, when not in use. This means restricted access for locked storage areas; office staff has greater responsibilities when in use, complete records storage areas may not be left unlocked during the day.
The change from paper-based records to EHRs has resulted in both can positive and negative impact on patient care. Some risks associated with EHR software is that defects that can go undiscovered for months and cause serious errors. Similarly, errors can occur when paper-based records have flaws in the documentation which can impact care negatively. Electronic health records are considered medical devices, which are held to a lower standard by the FDA, Hingle, S. (2017). The federal government sets measures to ensure that EHRs meet necessary technical requirements, but they do not assess the effectiveness and safety of EHRs (Hingle, S. (2017). EHR can reduce paperwork; improve coordination of care; create Legible records; Interface with diagnostic testing labs; Patient portals that allow interaction between the provider and patient to make care accessible; referrals are electronic and improved coding and billing
Documentation is a communication tool used by and between providers. By patient housing information in one database that is easily accessible and available allows providers to render the beat care possibly hence improving quality, safety, and efficiency. Through inputting correct and appropriate data ,services that can improve quality, safety, and efficiency. EHRs can help improve communication and allows for real-time access to complete patient records at the point of care which enhances transitions of care and patient experience.
Identify the challenges associated with implementing the EHR.
Implementation is challenging due to financial ramifications as well as a change in culture.it is A learning curve for many and can be challenging to care for patients, work through the functionality of the system and workflow, Verdon, D. R. (2012). Having the correct infrastructure can aid in the success of EHR.
Discuss the problems that may arise in the future as a result of many groups unwillingness to adopt the electronic health record as well as how changes to medical care (i.e., Affordable Care Act) can impact record keeping
The EHRs is essential for improving the quality and coordination of care. Lack of readiness pre-implementation can cause weakness of organization to transform the implementation of the EHR. EHR impacts patient safety and health care quality. EHRs may also reduce the costs of providing care. There have been incidences of the slow rate of adoption suggests that resistance among physicians they are the critical frontline users of EMRs. Miscommunication between vendors, IS leaders, and end-users have contributed to a multitude of problems in, implementation and utilization of the EMRs, Ajami, S., & Bagheri-Tadi, T. (2013). Physicians need to take the time to properly become familiar utilize with the EMR before, implementation and then trained to use it to get maximum return on investment. By using the extra time to learn the EHR, it improves efficiencies and the workflow.
The physicians need to have skills to listen to patients’ complaints, assess the medical condition, contemplate medical interventions, as well as type notes all at the same time. All of this requires a significant level of concentration, typing skills, and familiarity with the application’s user interface. As technology advances in the future, an automated scribe would be useful to ensure accurate documentation as well as maintaining patient satisfaction. The EMRs use could be increased through financial rewards for quality improvement and public reporting of multiple measures of quality performances. Reliability refers to the dependability of the EHR system.. As competition rises the market becomes very lucrative hence increasing the number of systems available.
Future of Records
Identify the future direction of health record keeping.
Paperwork can occupy up to a third of a physician’s workday, and residents spend as much as six hours per day documenting, Kamath, J. R. A., & Donahoe-Anshus, A. L. (2012). The ability to collect, integrate data into one operating system and to store data (e.g., imaging) remains a challenge. The implementation of an EHR must be planned and executed accurately to avoid the risks of misaligned and poorly implemented technology.Developing a governance and oversight structure approved by organizational leadership early in the journey is crucial.Involving the key stakeholders in development and implementation is vital
Discuss government and private sector intervention in the development of an EHR.
EHRs can save lives and save money as there is improvement condition of care and accurate billing. T Congress passed a law called the Health Information Technology for Economic and Clinical Health (HITECH) Act, giving hospitals and doctors estimated $20 billion to move forward with implementing and using EHRs Health IT Outcomes for EHR, EMR, POC, mHealth, Telehealth, & More. (n.d.). Retrieved January 27, 2018. Facilities need to demonstrate they are using EHR systems to improve care in compliance with the guidelines determined by the Office of the National Coordinator for Health Information Technology, Health IT Outcomes for EHR, EMR, POC, mHealth, Telehealth, & More. (n.d.). Retrieved January 27, 2018, Once organizations met the guidelines, they are given a payment or incentive form Davis, N., & LaCour, M. (2014). This encourages compliance and improves quality of care and data.
Discuss meaningful use and its impact on the development of the electronic health record.
To increase the use of electronic health record across both public and private sectors. Getting facilities and physicians to acquire EHR and use it will improve the quality of data. As we move from the traditional model of fee for service to the value-based model EHR plays an important role. EHR has immense value in healthcare delivery., malpractice insurance carriers view EHRs as a strategy to reduce exposure to risk.
A cost-benefit analysis is a tool which helps in financial decision making, EHR project generates a series of cash flows over its time. It is a substantial investment at the beginning by it does have befits through reduced cost and improved revenue, Running the Numbers on an EHR: Applying Cost-Benefit Analysis in EHR Adoption. (n.d.). Retrieved January 27, 2018. By utilizing CPOE system, there were significant savings from renal dosing guidance, nursing utilization, specific drug prescription guidance, and adverse drug reactions, Choi, Jong Soo & Baik Lee, Woo & Rhee, Poong-Lyul. (2013). There was a cost-saving noted on labor for filing and paper utilization.
Conduct a cost-benefit analysis between two similar organizations, one of whom chooses to adopt the electronic health records in their organization and one who does not.
Samsung Medical Center in Korea is a 2000 bedded facility which changed from paper to EHR Choi, Jong Soo & Baik Lee, Woo & Rhee, Poong-Lyul. (2013).,. They incurred a direct cost to build the system and the induced costs where incurred to ensure a smoother transition. The facility saved on office supplies, labor, and storage space. The initial cost savings came from adopting the EHR as operational costs were reduced. Patient volumes also influenced the value. After a 5year implementation, this organization saw a positive cash flow and was cost-effective Choi, Jong Soo & Baik Lee, Woo & Rhee, Poong-Lyul. (2013).,. In Sri Lanka a comparative study was done with EHR and paper documentation was randomly selected and compared to their outpatient department utilized EHR, Amarasiri, H., & Dorabawila, S. (2017). A hospital using paper documentation saw a reduction of stationeries, reduction of the patient queue waiting time, reduction in support staff number and decrease in indirect costs such as drug balancing and recording. The OPD generated a more considerable savings due to utilizing EHR.Patients spent an average of 24minutes in the OPD compared to 63minutes in the hospital which used paper documentation, Amarasiri, H., & Dorabawila, S. (2017). The wait time much shorter in the OPD due to efficiencies
Explain the pros and cons of each facility based on their decision and its impact on its revenue stream.
Health-care in the United States is dependent on paper processes for the patient chart, prescribing medicine, tracking diagnostic test results and billing. Transitioning to electronic health records will help improve this process, Kumar, S., & Bauer, K. (2011). Adopting EHR systems could lead to significant cost savings, reduced medical errors and improved patient health. Organisations need to track their quality metrics and ensure it meets the target to get fully reimbursed according to the value-based model.
In conclusion, the EHR provides organizations infrastructure to support the best patient care and experience. The EHR needs to be viewed as an investment in complete practice change. It changes the workflow in the majority of the care process and impacts most consumers. By supporting the process, can consumers as well as the organizations reap the long-term benefits and improve health care for the good of the public.
Schiza, E. C., Neokleous, K. C., Petkov, N., & Schizas, C. N. (2015). Patient-Centered electronic health: eHealth system development. Technology & Health Care, 23(4), 509-522. doi:10.3233/THC-150919
The Business Case For Implementing Electronic Health (n.d.). Retrieved from https://link.springer.com/article/10.1057/rpm.2009.14
Amarasiri, H., & Dorabawila, S. (2017). COST BENEFITS ANALYSIS OF ELECTRONIC MEDICAL RECORDS SYSTEM IN GOVERNMENT HOSPITALS IN SRI LANKA Abstract. International Journal of Social Science and Technology, 2(4), 1-12. Retrieved January 27, 2018.
Choi, Jong Soo & Baik Lee, Woo & Rhee, Poong-Lyul. (2013). Cost-Benefit Analysis of Electronic Medical Record System at a Tertiary Care Hospital. Healthcare informatics research. 19. 205-14. 10.4258/hir.2013.19.3.205
Running The Numbers On An Ehr: Applying Cost-benefit (n.d.). Retrieved from http://library.ahima.org/doc?oid=101607
Health IT Outcomes for EHR, EMR, POC, mHealth, Telehealth, & More. (n.d.). Retrieved January 27, 2018, from https://www.healthitoutcomes.com
Ajami, S., & Bagheri-Tadi, T. (2013). Barriers to Adopting Electronic Health Records (EHRs) by Physicians. Acta Informatica Medica, 21(2), 129–134. http://doi.org/10.5455/aim.2013.21.129-134)
Verdon, D. R. (2012). Documenting the disruption: Medical Economics EHR best practices study examines productivity declines when implementing an EHR system. Medical Economics, (12), 44.
Davis, N., & LaCour, M. (2014). Health Information Technology (3rd ed.). Retrieved January 25, 2018.
Kamath, J. R. A., & Donahoe-Anshus, A. L. (2012). Electronic Health Record: Adoption, Considerations, and Future Directions. In A. Kolker & P. Story (Eds.), Management Engineering for Effective Healthcare Delivery: Principles and Applications (pp. 309-332). Hershey, PA: Medical Information Science Reference. Retrieved from http://link.galegroup.com.lib.kaplan.edu/apps/doc/CX2700800028/GVRL?u=chic13451&sid=GVRL&xid=ac2eed2e