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Electronic Health Records

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Electronic Health Records: Transforming Today’s Healthcare

Abstract

Electronic health records have been revolutionizing the healthcare industry by facilitating enhanced care and safety to the patients and potentially saving millions of dollars. The EHR is a longitudinal electronic record of patient health information compiled from all the different encounters that an individual comes upon in various different medical care settings and automates all the data, allowing providers to have all the information in one electronic record. Electronic health records have enormous benefits to offer the healthcare industry, an important one being that they are permanent and cannot be lost; however, it is imperative that all facilities take the time, effort, and resources to incorporate it into their systems.

Electronic Health Records: Transforming Today’s Healthcare

The electronic health record and the use of clinical informatics have made great strides in improving the quality of care we provide for the population and also saving the industry millions of dollars. “The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting.” (HIMSS, 2011) Nurses play an important role in helping to facilitate the success of the EHR because they are often at the forefront in the documentation process in many healthcare settings. The EHR uses clinical document architecture (CDA) data standards. Using one type of standard and structure allows the EHR to be used in all different settings and the format is intended for use by many different kinds of clinical documents. The CCD, Continuity of Care Document, uses the CDA to provide a summary of the patient’s health information which enables the EHR to be shared among different providers. There are electronic medical record systems that automatically monitor clinical events and symptoms and can use the patient data to predict and detect potential adverse events. The EHR will prompt the clinician to watch out for the discrepancy and/or change the drug or procedure to better accommodate the patient. The EHR is also more private and secure then the paper chart because it is recorded whenever the chart is opened and by whom. Only a minority of healthcare facilities in the US today has adopted the EHR due to costs, lack of incentives to implement new programs, and physician’s fear of being slowed down. Cutting down production costs will help global companies stay afloat and research methods, in-depth reports, and profit availability reports will help companies achieve that.There are no current universal standards for the adoption of electronic health records but an effort to create them is under way. Electronic Health Record;

Topic Availability

The electronic health record has been in existence for about 3 decades but it is in recent times that it has become a priority to incorporate it into primary care facilities. A search was done on Ebscohost using the words “electronic health record” to see how much literature is available on the topic. Since 2007 there are 83 scholarly peer reviewed journals available and 1476 non peer reviewed articles. The oldest article that was found on electronic health records was written in 1994. Since that time there are 2048 non peer reviewed articles and 572 scholarly peer reviewed journals written on the subject.

Besides for the literature written on the topic, there are organizations created to educate the public on the values and benefits of EHR and to provide support that facilities need to incorporate it. HIMSS (Health Information and Management Systems) is a non-profit organization that is dedicated to improving the quality, safety, and cost effectiveness, and access to healthcare through the use of informatics, technology, and management systems. HIMSS represents over 23,000 members, the majority of them working in a healthcare setting. Their website is extremely informative and has a wealth of information regarding EHR usability, global EHR, and EHR adoption. The information is only available to HIMSS members.

In September 2008, Pete Stark, Chairman of the Committee on Ways and Means Subcommittee on Health, introduced House Bill 6898, the Healthcare e-Information Technology Act of 2008. “This bill is intended to stimulate the development of a uniform, interoperable health information technology (HIT) system for America.” (Stoten, 2009) The Healthcare e-Information Technology Act will coerce facilities in the US to make the transition to EHR, thereby providing more organized care to the patient population.

Information Availability

The dozens of scholarly peer reviewed journals that are available on the topic of electronic medical and health records are geared toward healthcare providers. Many of them are case studies showing how advantageous the EHR is when determining certain trends in the medical world, such as the high incidence of advanced breast cancer in certain communities. Using the electronic medical record and its systems, the researchers were able to conclude that these underserved women were not getting regular mammography screenings and therefore were only being diagnosed with breast cancer when it was already advanced. The EHR was then used to detect and remind high risk women to go for regular mammograms. Some of the journals are written for providers and nurses explaining the use of clinical decision intervention systems that are many times incorporated within the EHR. Many of the journals are written to help healthcare professionals understand the need for electronic health monitoring and recording and offers information on how to use it. There is a lot of information written on ePHRs, personal health records, which is not in the scope of this paper, but these are records that are used by the patient and sometimes in conjunction with the EHR. Many of these articles are written to encourage providers to incorporate these systems into their EHRs, while some are written for the regular patient population to explain the benefits of using a PHR.

Personal Views

Technology has the ability to save huge amounts of time and resources. Electronic health records are a wonderful tool that provides enhanced patient care that benefits both the healthcare provider and patient. The hours that patients spend waiting to see a provider would be cut down immensely with the use of EHR. The clinician can pull up the patient’s chart and in seconds see his laboratory tests, blood work, vital signs, and other important health data with the click of a button. With the use of clinical intervention systems, the provider would have orders and suggestions available on the screen to choose from and would be able to print out the orders and information for the patient immediately. This system eliminates the miscommunication that patients and doctors often experience which causes a patient to be accidentally noncompliant with his healthcare and to make medication errors. I have seen this occur in my personal life with my grandmother who has multiple health issues. She saw a new cardiologist that prescribed her a new diuretic and was not clear that she should discontinue the one she was already taking. Fortunately, she did not overdose for too long before realizing that she did not feel well and attributed it to the new medication, but this happens on a daily basis and can cause devastating effects and even death to occur. With EHRs doctors will be able to print out a list of the patient’s medication and will be able to make the changes electronically. If a provider is careless or makes an error, the EHR can alert him/her to recheck the order. An electronic recording system greatly improves patient safety and clinical intervention and precision.

Conclusion

The implementation of a national electronic health record system would greatly improve patient safety and reduce costs for the United States healthcare industry. The use of EHRs has provided the benefit of more organized collaborative care for the chronically ill patient with co-morbidities and has facilitated improved continuity of care. There are attempts being made and incentives being offered to encourage providers to adopt the electronic health record and a lot of literature is available describing the enormous benefits that it provides. Once the US gets over the hurdles and makes the change from paper to electronic, the healthcare system will transform and provide great benefits to both the physician and patient.

References

Brokel, J. (2009) Infusing clinical decision support interventions into electronic health records. Urologic Nursing, 29(5), 345-352. Retrieved on April 29, 2011 from EBSCOhost. Chaudry, R., Tulledge-Scheitel, S., Thomas, M., Hunt, V., Liesinger, J., Rahman, A., Naessens, J., Davis, L., Stroebel, R. (2009). Clinical informatics to improve quality of care: a population-based system for patients with diabetes mellitus. Informatics in Primary Care, 17(2), 95-102. Retrieved on May 3, 2011 from EBSCOhost. Clark, C., Baril, N., Kunicki, M., Johnson, N., Soukup, J., Lipsitz, S., and Bigby, J. (2009). Mammography use among black women: the role of electronic medical records. Journal of women’s health, 18(8)1153-1162. Retrieved on May 4, 2011 from EBCSOhost. Follen, M., Castaneda, R., Mikelson, M., Johnson, D., Wilson, A., and Higuchi, K. (2007) Implementing health information technology to improve the process of health care delivery: a case study. Disease Management, 10(4), 208-215. Retrieved on May 1, 2003 from EBCSOhost. HIMSS, Healthcare Information and Management Systems, 2011. Electronic Health Record. Retrieved on May 19, 2011 from http://www.himss.org/ASP/topics_ehr.asp. Kmetik, K., O’Toole, M., Bossley, H., Brutico, C., Fischer, G., Grund, S., Gulotta, B., Hennessey, M., Kahn, S., Murphy, K., Pacheco, T., Pawlson, G., Schaeffer, J., Schwamberger, P., Scholle, S., and Wosniak, G. (2011) Improving Patient Care: Exceptions to outpatient quality measuresw for coronary artery disease in electronic health records. Annals of Internal Medicine. 154(4)227-234. Retrieved on May 4, 2011from EBSCOhost. Pakhomov, S., Shah, N., Hanson, P., Balasubramaniam, S., And Smith, S. (2010). Automated processing of electronic medical records is a reliable method of determining aspirin use in populations at risk for cardiovascular event. Informatics in Primary Care, 18(2), 125-133. Retrieved on May 3, 2011 from EBSCOhost. Schnipper, J., Gandhi, T., Wald, J., Grant, R., Poon, E., Volk, L., Businger, A., Siteman, E., Buckel, L. (2008) Design and implementation of a web-based patient portal linked to an electronic health record designed to improve medication safety: the Patient Gateway medications module. Informatics in Primary Care, 16(2)147-155. Retrieved on May 3, 2011from EBSCOhost. Stoten, S. (June, 2009). Health Policy Issue with the Electronic Health Record. Online Journal of Nursing Informatics (OJNI), 13, (2). Retrieved on May 22, 2011 from EBSCOhost. Thede, L., (August, 2008) "The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves?" OJIN: The Online Journal of Issues in Nursing 13(3). Thede, L., & Sewell, P. (2010). Informatics and nursing: Competencies and Applications (3rd Ed.). Philadelphia: Lippincott-Raven Publishers

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