HealthCare Management

HIM 500: Healthcare Informatics

Module Three Activity

By: Stephanie Shea

7/7/2017

What is an EHR?

EHR stands for electronic health record and is a digital record of health information. Unlike paper medical charts, information found in an EHR is in real time and can be accessed by several authorized users at once. (“What is”, 2013). Not only does an EHR improve access to patient information, it also reduces paper record storage and ensures increased security of sensitive patient information. The National Alliance for Health Information Technology (NAHIT), defines the EHR as “an electronic health record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.” (Green, 2015).

What types of information are found in an EHR?

All kinds of clinical and administrative data can be found in the medical record. Administrative data includes basic registration and financial information such as name, date of birth, contact information, and insurance. Clinical information may include past medical history, active problem lists, medications, treatment plans, vital signs, allergies, radiology, and lab/test results. Additionally, there are progress notes in an EHR which contains information from all clinicians involved in patient care.

Who manages an EHR?

As mentioned above, any authorized clinician involved in the patient’s care can manage information within the EHR. Physicians are the main discipline involved in managing information. They enter orders, history and physicals, discharge summaries, progress notes, and review test results. However, other members of the interdisciplinary team include nurses, physical/occupational therapists, speech language pathologists, dietitians, respiratory therapists, social workers, case managers, coding/billing specialists, pharmacists, laboratory, and radiology techs to name a few. These disciplines may not enter orders but will document in patient flowsheets, test results, and progress notes. It is important to reinforce that only members of the medical team providing care to the patient can manage health information. Reviewing protected health information without authorization is not allowed.

How is it used?

Information within the EHR can be used in a variety of ways depending on the discipline. The overarching theme for how the EHR is used is to provide communication and clear, legible documentation regarding the patient’s care. However, an EHR typically goes beyond documentation. Instead it incorporates more individual practice workflows which can help to improve coordination of care, quality of care, cost savings, and improved efficiency. (Practice Fusion, 2016).

Does an EHR follow the patient to other health facilities? Explain.

Several of our readings indicate that yes, the EHR does follow the patient to other health care facilities. This can include laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and clinics. However, I have not fully experienced this in practice yet, mainly because so many facilities have different EHR systems.

I’ve worked in two large academic medical centers throughout my career and neither has been able to electronically send or receive information from the EHR, unless they are coming from one of the other sites within the hospital enterprise. In my experience, when patients are transferred and received from other facilities, key documents are printed and faxed over by the social worker or case manager; essentially creating a paper chart. This has caused some problems because sometimes not all information is available from all disciplines. For example, as a dietitian, often the clinical nutrition notes are missing. Therefore, a phone call to the facility is usually required to determine the patient’s nutritional status prior to admission or to handoff care plan recommendations. One initiative we are working on is improving these transitions of care, ideally through IT innovations. Additionally, we are working on an initiative in collaboration with a subacute rehab facility across the street from our hospital where oncology patients can be transferred back and forth as needed for blood transfusions. There is an IT subgroup working on the challenges of dealing with two different EHRs and how our providers (the more specialized team) will be able to access the patient information to assess if the patient requires a transfusion. There are barriers to accessing lab work at two different facilities that need to be overcome. I suppose this is one of the key differences between an electronic health record (EHR) and electronic medical record (EMR). Health information within an EHR is supposed to easily move with the patient; while an EMR is not designed to be shared or travel outside of the facility. (Practice Fusion, 2016).

References

What is an electronic health record (EHR)?. (2013). Retrieved on July 7th, 2017 from

https://www.healthit.gov/providers-professionals/faqs/what-electronic-health-record-ehr

Green, M. A., & Bowie, M. J. (2015). Essentials of health information management: principles

and practices. Boston, MA: Cengage Learning.

Practice Fusion (2016). EMR vs. EHR. Retrieved on July 7th, 2017 from

http://www.practicefusion.com/blog/ehr-vs-emr/