STENBERG COLLEGE
Learning Assessment 2: December 17, 2018
MED 205 Introduction to Health Information Systems
CATD 0118: Jody Cusack
Introduction
What is an Electronic Health Records (EHR)?
Digital technology has improved the way we can retrieve information instantaneously every day with the use of smart devices such as cell phones and tablets that provide not only storage of files, images, algorithms, and apps with industry-related sources etc. (even this WebQuest page was able to be created through digital technology). Additionally, digital methods also create fluency of internet to search topics of uncertainty and give us constant access to sources of information to help answer questions and solve problems. In this digital fashion, EHR's are virtually-stored, secured, means to obtain patient information such as demographics, underlying pathological problems, prescribed medication, allergies, medical history, and contain diagnostic test results such as blood panel results, echocardiograms, ECG's, or CT images. Since EHR's are digital, a superior alternative to paper charts, physicians practicing medicine can access patient information from anywhere, at any time which creates improved patient care and utilizes the stored patient information within electronic health records to effectively treat the patient in a timely manner.
Task
What are the benefits of EHR?
Benefits of Electronic Health Records (EHR)
These digital systems greatly benefit the quality of patient care within healthcare systems as having secured access to a patient’s confidential medical history, such as allergies and test results, means that physicians can immediately access patient information and provide the most appropriate care for the individual. For example, in cases where a patient cannot communicate (loss of consciousness) the data stored within EHR’s can provide essential details-such as test results which greatly impact how their treatment is determined since educated decisions on patient care can be made by the physician. As mentioned by the online article ‘Benefits of EHR’s’, digital access to patient records provide information whenever and wherever it is needed. This means that the results of EHR use are improved patient care, increase patient participation, improved care coordination, improved diagnostics and patient outcomes, practice efficiencies and cost savings (HealthIT.gov, 2017).
What are EMR's (Electronic Medical Records)?
In contrast to an Electronic Health Record (EHR), and Electronic Medical Record (EMR) is a specialized form of patient health record storage. EMR's are digital records clinicians maintain to store information on their own patients, and therefore is often more detailed or specific to patient treatment within that clinic. These EMR digital storage systems allow for the independent medical practice to schedule and store patient appointment details, demographics, diagnostic imaging (CT, X-ray, echo etc.) current and past medical history, prescription drug history, and diagnostic information, especially laboratory test results or biopsy findings ordered for the patient by the physician within the practice. For example, a dermatology practice may have an EMR that contains labeled diagrams of the patient that undergoes annual “mole mapping” appointments in melanoma prevention if the patient is at increased risk with pre-disposing factors. If the dermatology practice performs minor surgical procedures such as biopsy excisions the EMR allows the physician to create detailed biopsy notes on the patient (s) procedure which may include the area of biopsy, what was excised i.e. atypical nevi, type of local anesthetic used, methods-punch or shave excision, how the patient responded (i.e. syncopal episode, infection post-procedure, hypertrophic scar formation). There are various EMR software programs, so the information stored and uses may vary but most EMR’s allow the program to simultaneously merge with other software that can also be used in physician billing scheduling (Canada Health Infoway, n.d.).
Process
How Information Enters Electronic Health Records
1) New Patient enters Healthcare system. Personalized, unique Provincial Healthcare # is assigned to the individual along with their legal name and DOB as identifiers.
2) Diagnostic tests performed on the patient verify correct patient via unique healthcare #, name, DOB to confirm the correct patient results are uploaded into the secured EHR system underneath the individual’s profile.
3) When or if necessary, physicians and other designated healthcare workers can access the EHR with a secured digital signature use. The patient information is accessed by searching the unique patient identifiers (healthcare #, DOB, legal name) to access patient information and diagnostic test results from the digital EHR system for instant knowledge, enabling faster and informed treatment decisions.
Evaluation
Role of Electronic Health Records in Efficiency of Practice and Patient Care
Electronic Health Records (EHR) enable numerous benefits to the patient and also to the physician as they ease access to the patient’s pertinent medical information. In this era, there is no logic in depending on archaic paper-based systems to store patient records as access is limited, the method is time-consuming, takes up physical space, and creates a larger margin of error. As mentioned by O’Connor, having an EHR puts you at a competitive disadvantage with modern, computerized medical practices since Electronic health record or EHR software will streamline many of your core processes, from beginning new patient charts to updating records during treatment. Also, Practices now have the option to run EHR software on their own servers or to deploy a cloud-based EHR solution that will take a lot of pressure off of their own Information Technology department (O’Connor, S., 2017).
Conclusion
Efficiency, Safety, and Accessibility: Electronic Health Records
Electronic Health Record systems and Electronic Medical Record systems enable safer, more efficient medical practice and create a smooth transition for patients whenever having procedures or diagnostic tests performed. These systems are beneficial because they are secured yet allow access to designated personnel immediately when needed. The errors or limitations within these digital information systems lie primarily within data entry errors from human distraction, but these limitations can easily be resolved with proper staff training and double-checking the entries. Plus, they eliminate the need for paper-chart use which saves trees, so we can consider electronic health and medical record systems as being environmentally friendly, an additional benefit to the numerous advantages provided by digital systems.
Credits
References
Canada Health Infoway EMR. (n.d.). Retrieved December 17, 2018, from https://www.infoway-inforoute.ca/en/82-our-partners/vendors/certificati…
HealthIT.gov. (2017). Benefits of EHR’s. Retrieved December 17, 2018, from https://www.healthit.gov/topic/health-it-basics/benefits-ehrs
O’Connor, S. (2017). Advanced Data Systems Corporation. How do EHR Systems Work? Retrieved December 17, 2018, from https://www.adsc.com/blog/how-do-ehr-systems-work