Electronic Health Records Speaker Notes

In a healthcare world that operates on stringent budgets and margins, we begin to see the need for a higher capacity healthcare delivery system. This in turn puts pressure on the healthcare organizations to ensure higher standards of patient care, and compliance with the reform provisions. However, these are the harsh realities of today’s healthcare environment, a setting in which value does not always equal quality. The use of technology can help to amend some of this by providing higher capacity care without compromising quality; this can be done with the use of such technology as electronic health records (EHRs). This paper will aim to address how EHRs influence healthcare today by expanding upon topics such as funding sources, reimbursement methods, economic factors, socioeconomic factors, business influences, and cost containment.

The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies. The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. (Huston, 2013)

After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital

EHR was created to have a technical way to securely exchange private and personal medical health information in hopes to improve the quality of care, decrease medical errors, limiting paper use, reduction of health care cost, and increasing a person access to affordable health care. A mandate was created for EHR stating that health records can be accessible to all facilities with patients having the capability to access their own health records at any time. Ameliorating the quality and convenience of care given to a patient, allow for cost saving measures, engage the patient and family to participate in their care, improve accuracy of medical diagnosis, and enhance the efficiency of the overall outcome of the patients’ health.

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

A pivotal aspect of receiving quality medical care is being able to communicate your health concerns and have confidence and trust in your doctor, which is essentially the doctor patient relationship. Yet, this

Patients come to the physician because of a problem that they are having and with that notion they are prepared to give full details of their problem. Giving information to the medical staff is a

Patients seek medical attention for preventative measures, as well as, diagnostic measures. Patients must have a trusting rapport with their collaborative medical team, as the nurses and the doctors are the people who they trust their lives with. Patients do not always present to hospitals, urgent cares, walk-in clinics, or even doctor’s offices only when they are sick; patients visit to ensure their good health will continue, treatment regimens are of benefit, changes that may be needed in regimen. When someone thinks of a patient they may think of some of these characteristics: illness, disease, hospital, medications, health, and prevention.

Technology has come a long way over the years and continues to advance rapidly. The health care system is greatly affected by the advancements in technology. An example of this would be the use of electronic health records (EHR). In this paper I will be describing the electronic health record system. How my facility has initiated the EHR with following the six steps and describe meaningful use and how my facility is working towards this. Lastly I will discuss how to maintain patient confidentiality with use of EHR, and what my facility is doing to prevent HIPPA violations.

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Patient care is our highest priority. We understand that a mutual trust must be established between the doctor and patient in order to ensure that the patient can receive the care that he or she deserves. Our physicians build trust with the patients by taking time to discuss

“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an

I believe the biggest problem facing doctor-patient communication in acute visit scenarios has to do with the overall doctor’s performance. Personally, I feel during a doctor visit, the doctor needs to respect the patient, explain in a calm and understandable matter what needs to be done, and to listen to everything the patient has to say. I strongly believe that it is the doctor’s responsibility to cater to the needs of their patient. Furthermore, I think it’s very important for the doctor to address every single concern of patient and if the doctor cannot do this, this will make the patient not able to trust the doctor and to feel uncomfortable. If that happens, the patient is going to no longer want that doctor as their own and will seek

The patient-physician relationship is a principal factor of quality patient care. The purpose of this study is to define the most prudent factor in a patient-doctor relationship. By determining, what the patient needs are while in consultation with his or her healthcare provider is an important aspect of the patient’s outcome. The ability to maximize the utility of both the patient and doctor’s time could prove to be satisfactory and efficacious. The administration of countless studies had been conducted for physicians to determine the most competent way to care for the patients, but not from a patients’ point of view. A cross-sectional survey is appropriate for this study so that patients can rate the importance of each factor. A sample

Physicians should avoid engaging in long dialogues in front of the patient. It is far better for the physician to keep to short statements and clear, simple explanations. Again, physicians should be sure to ask whether patients have any questions so that understanding can be checked and dialogue promoted. It is wise for the physician to avoid the use of jargon whenever possible, particularly with elderly patients.