Electronics Records For Patients Essay
Electronic Medical Records or Computerized Medical Record System what is it and what are the advantages along with the disadvantages of using this system? That is what we will discuss in this paper.Electronics Records For Patients Essay
Electronic Medical Records (EMR) is a computerized database that stores all of the personal and medical information of the patient’s care and billing information by the health care providers. Today, only the providers and medical practices can implement these systems.
Healthcare can be known for a complex industry. Every day is a new day facing complicated clinical administrative transactions with electronic medical records and safety? Health Information technology is suppose to realize errors using electronic medical records. Leaders must understand the complexity and safety issues in order to help mandate electronic medical records with design, development, implement and use. In the last decade, this article has informed executives, clinicians, and technology. Their main focus was on these three areas computerized physicians order entry. Their main focus was to work all three areas computer physician order entry, computer decision support system, …show more content…
Health care is the most complex system with complicated transactions that could result in behavioral changes. One way is patients and clinicians should demonstrate how challenging it is to help maintain patient information.Electronics Records For Patients Essay Clinical information systems by difficulties in demonstrating they are also challenged in maintain patient health information. Another land mark article described anecdotal evidence that while electronic medical records and associated clinical information systems can reduce errors, they can also cause errors. (Bates et al. 2001) Computerized physician order entry has reduced errors in patient care by trying to eliminating illegible orders and transcriptions errors. Researchers also found that computerized physician order entry can increase the coordination load among clinician resulting in new opportunities for new sources of error. (Cheng et al.2003) A nurse may be unaware of new patient order by soling imputing the information into the computerized physicians order.
1. Paper medical records still have a place in healthcare, but the complexities of healthcare, its information and the numbers of providers that treat one patient are becoming unmanageable by paper files. Discuss the strengths and weaknesses of paper medical records?
The strengths include;
• A patient file can be more mobile
• Documentation is fast so charting can be completed immediately
• No need to wait for an available computer terminal.
• Electronic systems can be slow. Paper systems don’t require electricity so theys are never “down” and maintenance is never needed.Electronics Records For Patients Essay
The weaknesses include;
• Possible incomplete charting.
• Complete charts can be misfiled or lost. Possible damaged or destroyed information without a backup system.
• Illegible handwriting.
• Charts can be incomplete with missing labs, diagnostics, and radiology reports or they can be misfiled in the wrong patient chart.
• Some charting is done at the end of a shift and treatment errors may not be identified until it is too late.
• Various abbreviations can be dangerous when misused or misinterpreted.
• A patient may have several very large files with complex diagnoses and treatments.
• Storage for paper files can take a large amount of space and can be costly.
2. Discuss the strengths and weaknesses of Electronic Medical Records and the ways they could help in the delivery of nursing care.
• Data can be entered immediately, in real-time so patient care can be safer and outcomes can be improved by letting providers and nurses have access to the information when they need it.
• Doctors orders would be clear and legible so mistakes could be avoided.
• The information can be located in one central place avoiding loss of information and easily found in case of an emergency.
• Patient information is easily stored and there is no need to wait for a patient file or chart, current information can be immediately provided.
• Calculations can be done automatically by the computer helping to avoid mathematical errors.Electronics Records For Patients Essay
• Current medications along with dosages are noted and the time the nurse gives them can be documented along with adverse side effects and medication compatibility.
• Patient allergies can be visible and noted in several places to avoid mistakes.
• Electric documentation includes “prompts” to streamline documentation and helps to ensure the nurse does complete charting.
• Weaknesses include the lack of ability for systems to talk with each other so they are unable to share information so nurses need to learn more than one system and have different passwords which takes time away from patient care.
• Not all nurses are technologically competent; training will be needed for them to use the system effectively.
• Abnormal lab, radiology and other diagnostic results would be visibly indicated along with normal values
The Benefits of EHR
Benefits of Electronic Health Records (EHRs). Retrieved from https://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs
This article covers the different benefits of the electronic health record. The different benefits include improved care coordination, improved patient care and it increases patient participation. This article shows a few different case studies and patient diagnoses and outcomes associated with them. It explores the cost saving benefits and the efficiencies associated with the use of electronic health records. I enjoyed this article because of the way laid out the benefits in a way that was easy to understand and helpful.
Concerns and Benefits of the Public with the Adoption of Electronic Health Record
Medical Mastermind. (2014). Most Patients Desire EHR Used Despite Security and Privacy Concerns. Retrieved from https://medicalmastermind.com/blog/most-patients-desire-ehr-use-despite-security-and-privacy-concerns/
This article explores the public wanting to use electronic health records with the concerns of privacy and security compared the public using paper records and their feelings on their privacy and security. The Office of the National Coordinator for Health Information Technology (ONC) conducted a survey to explore the differences on how patients feel about their privacy and security based on if they have paper or electronic health records. The findings from the ONC show that overall patients using electronic health records are less concerned with both their privacy and security compared to patients with paper records. I enjoyed this article because it explores the differences in opinion.Electronics Records For Patients Essay
Electronic Medical Records are associated with many functions within the health care system. Patient health records contain important information, such as patient health care, financial breakdown, legal information as well as detailed research and quality improvement cases.
Such information is always necessary within the medical field, hence it needs to be shared amongst many professional medics within the health care field. Such demand makes it a little cumbersome to use paper health records calling for the development of an automated health recording system.
Electronic Medical Record will provide chances for improving quality of care and patient safety within health organizations. The system will help in providing solution to the challenge of dealing with integrated healthcare delivery by providing detailed, reliable and accessible timely information on patient health status across the medical field whether in primary or secondary health care.
The EMR will reduce the costs on keeping paper records as well as decreasing inefficiencies within health care sector. The EMR has got increased storage capabilities enabling data to be stored from any region and for longer periods of time, enabling instant retrieval of information to many people even in remote sites (Young, 200, p 99).Electronics Records For Patients Essay
The idea on fragmentation of clinical records posed by paper records will be minimized hence reducing costs, which could have been otherwise incurred on current and future patient care (Schloeffel, 2001, p 1). The built-in intelligence capabilities of the EMR system will assist in recognizing abnormal laboratory results. The system provides efficient access to protocols, care plans, critical paths and other databases on healthcare knowledge such as pharmaceutical information (Borkowski, 2009).
Start-up costs might be of disadvantage to many since it can be excessive at times. Allocation of capital to information system provides added costs on health care expenditure. Another disadvantage is that it requires substantial technical knowledge for the system to be used efficiently. This calls for all the physicians and clinicians to have prior knowledge on the system operation for purposes of realizing benefits of interactive on-line decision support (Borkowski, 2009).
Proposal on Implementation of CPOE
Computerized Physician Order Entry (CPOE) presents one of the point-of-care products which will help in playing the key role in dealing with the cases concerning patient safety objectives.Electronics Records For Patients Essay
The system involves electronic communication of orders as well as detailed protocol for checking against drug references and other medical information. CPOE is physician-focused and will help in the issues of developing fewer medication transcription as well as order errors. The tool will help most physicians in selecting correct medication and therapies for each patient.
The equipment’s ability to customize ordering processes will assist in easy identification of physician needs and most importantly allow for prevention of problem occurrence by counter checking errors before completion of any order. The tracking system involved in this technology will help clinicians and physicians to evaluate their actions and compare to those of their peers in addition to comparing treatment recommendations within the given standards and guidelines (Borkowski, 2009).
However, the CPOE may not be effective on its own until it is integrated together with other crucial clinical information systems. Another disadvantage is that there is still possibility of incurring errors within the system owing to the natural assumption that computers are always right.
There are also multiple steps involved in operating multiple screens required for completion of order signing. This proves to be time-consuming when used by many people is at the same time. Frequent computer access might not be possible, especially in cases where only few computer stations are available in spite of many users (Borkowski, 2009).Electronics Records For Patients Essay
Changes within organizations normally occur either as planned or unplanned. Planned changes are known to arise from either single or series of changes linked to organization goals and objectives. While unplanned changes normally arise as a result of the unexpected uncertainties within the organization.
Various changes are required for the purposes of incorporating the modern computerized equipment with the work environment. The change undergoes three environmental stages including; societal environment, task environment then finally internal environment. Within the societal environment, EMR technology will have to be approved by the legal authorities within the government by looking at its technological and economical impacts within the health sector (Borkowski, 2009).
Technologically the equipment has the capability of speeding up the recording on individual health matters as well as ability to store large amount of data and sharing it over wide area within the shortest time possible. It saves on costs since it makes health records available within reach of medical practitioners and patients.Electronics Records For Patients Essay
The socio-cultural forces which tend to oppose the nature of the records in exposing patients medical records to the public would be dealt with by promising confidentiality to the patients’ medical information through the use of specified passwords.
Only the patients and trusted medics would be allowed to use the specified password whenever they want to access the patient’s medical information for the purposes of further treatment. Legal acts like the HIPAA would be enforced to ensure that tough measures, including fines are imposed on those trying to misuse individual’s medical records discriminatorily. In some places, employers use medical records to discriminate individuals on employment opportunities (Borkowski, 2009).
The task environment includes several players such as employees, special interest groups, competitors, customers amongst others. Dealing with competitors will call for marketing the superior abilities and qualities of the technology. Employees would be placed on thorough training on how to use the equipment confidentially without loosing on the confidence of the patients concerning their medical records. Suppliers would be endowed with the task of working with computer specialists for the purposes of EMR installations.Electronics Records For Patients Essay
Internal forces related to the structures, processes as well as resources within the organizations which at times lead to low profit margins could be addressed by ensuring the efficiency of the equipment through delivery. This could save on costs required for the storage of large amount of documents; the technology would as well confine all medical data to one source making it easier for services to be delivered without fragmented processes (Borkowski, 2009).
Some of the challenges involved include such cases as lack of autonomy, especially in the process when patient’s data is shared amongst health care providers without informing the patient. The exposure of patient’s data does not guarantee fidelity in any way since it can be stolen by unknown parties. This could easily lead to compromised treatment within the society since patients may be overwhelmed by fear of exposure.
Conflicts arise within the medical ethical principles concerning safety of patient health records. There is a breach on confidentiality and right to privacy on the side of the patients. Hence patients can easily be discriminated within the market place as mentioned earlier in the article (U.S. Department of Health and Human Services, 1998).
Computer-based Electronic Health Records presents one of the technological advances within health care system. Such technology is of great benefit in health sector since it has helped in improving the level of access and quality at affordable costs.Electronics Records For Patients Essay
On the same note, computerized system will help in providing accurate information on billing hence allowing medics to forward any payment claims electronically. This would ensure timely and efficient payment to health care providers. It would save the patient hectic time, which might arise in providing information over and over whenever they seek medical attention (Lohr, 2007).
The use of computerized medical systems enables improvement on the quality of care provided and also guarantees reduction in medical errors. There is improvement in the level of efficiency and reduction in medical costs since the methods enable easy coordination between health care providers on patient’s care. The system would enable smooth transfer of information, eliminating the possibilities which had earlier been experienced in duplication of health information by the third parties (Hartzband and Groopman, 2008).
Approximately 75% of the people in Ontario have electronic medical records and about 10,000 Ontario doctors use them to improve patient care, achieve health outcomes, and improve patient safety doing. Electronic Medical Record (EPR) is a clinical desktop application of UHN standard developed by UHN’s Shared Information Management Service (SIMS). Healthcare workers can quickly and easily access multiple patient records in real time and have easy access to other integrated applications.Electronics Records For Patients Essay
Electronic medical records are defined as files stored on a computer that records all important information about the patient’s current health status and medical history. Using electronic medical charts (EPR) eliminates the need to store patient records in a hard copy at clinics and hospitals. Electronic charts are easier to understand because they are easier to move from one system to another and handwriting systems are bad. Since patient identity always exists, EPR can also improve patient safety (Roy, 2009). Definition of Electronic Medical Record
The terms EHR, EPR, and EMR are often used interchangeably, but differences between models are currently defined. Electronic Health Record (EHR) is a vertical collection of electronic health information about individual patients or groups. In contrast, EMR is a patient record created by a vendor for a specific encounter at a hospital or outpatient and can be used as a data source for EHR. Federal and state governments, insurance companies and other large-scale medical institutions are promoting recruitment of electronic medical records. The US Congress has two incentive programs (up to $ 44,000 per doctor based on Medicare or up to $ 65,000 for six years under Medicaid) and a fine (ie,Electronics Records For Patients Essay
Electronic health records are digital or electronic records of patient health information collected in the history of interactions between patients and health care systems. Electronic health record keeps all information about patient’s health. Information including age / gender, drugs and vital signs, past medical history, laboratory data, and radiology reports vary. The concept of medical report dates back to the 5th century BC and was developed by Hippocrates, a Greek doctor, also known as Hippocrates oath. Hippocrates explained the two main goals behind his discovery – medical records should accurately reflect the course of the disease 2. Medical records should indicate the cause of the disease. Currently, electronic health records first appeared in the 1960’s. According to reports, at least 73 hospitals are beginning to use electronic medical record systems. The study concluded that electronic health records are the future
Electronic Health Records are an easy way to have all of the patient’s information in one place. Most doctors offices and hospitals are moving towards Electronic Health Records and doing less paperwork, while this might sound like a great idea to have all of your information in one place it still doesn’t replace paper charts just yet. While most do use Electronic Health Records, there are still doctor’s offices that you have to fax information to that don’t have Electronic Health Records. This leads random paperwork for the hospital and the doctor’s office and because not everyone has Electronic Health Records, this can have a bad effect on the patient’s health and life.Electronics Records For Patients Essay
Since Electronic Health Records are something new, they are still working out all the kinks. For example, although you might think they have all of your information in their computer but in most cases there are things missing. Some of this information might not mean much to diagnosing you but if something very important is left out it can kill you. There is also bad things that can happen with paperwork as well, it gets lost or misfiled and that is information that is important that is just gone.
The increase of Electronic Health Records has lead to less paper records but some places use a hybrid of the two, which can lead to lost information. The hybrid method used by some practices has lead to malpractice claims because a patient’s information was lost and caused something serious to happen to them, all because they didn’t have the information or they didn’t have the right information. Another downfall is that some Electronic Health Records systems can’t communicate with each other, so information still has be faxed over. Cerner Corporation and Epic Systems are two of the biggest systems used by hospitals but you can’t share information from one system to the other.Electronics Records For Patients Essay
Sharing information is a very important part of getting the right diagnosis and preventing complications. The health care system needs to make up its mind on whether to use paper or computers to store their information. This will prevent lost information and help the health care system run better. If they decide to use Electronic Health Records, then they need to have one system that can store all of the information and that they can share with other systems and make sure they keep up to date records of all patients. Electronics Records For Patients Essay
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