Introduction to Health Information
HTH 2304, Introduction to Health Information Management 1
Course Learning Outcomes for Unit III Upon completion of this unit, students should be able to:
1. Discuss the legal aspects of health information management. 1.1 Discuss legal issues that impact electronic health records.
7. Assess the impact of emerging health information technology applications on the healthcare industry.
7.1 Discuss the technology changes from paper documentation to electronic documentation.
Course/Unit Learning Outcomes
Learning Activity
1.1
Chapter 5 Article: “Redefining the ‘Legal Medical Record’ and How to Be Prepared to
Respond to Legal Requests for a Patient’s Legal Medical Record” Unit III Assessment
7.1
Unit Lesson Chapter 5 Article: “We Want People to have Access to Their Medical Data on Their
Smartphones” Unit III Assessment
Reading Assignment Chapter 5: Electronic Health Records Additional Reading Assignment: In order to access the following resources, please click the links below. Arndt, R. Z. (2017). We want people to have access to their medical data on their smartphones. Modern
Healthcare, 47(34), 30. Retrieved from https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest- com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1931806312/AB94CC8C67B04 D08PQ/1?accountid=33337
Finkelstein, M. M., Esq. (2017). Redefining the “legal medical record” and how to be prepared to respond to
legal requests for a patient’s legal medical record. The Journal of Medical Practice Management: MPM, 33(1), 11–14. Retrieved from https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest- com.libraryresources.columbiasouthern.edu/docview/1933854979?accountid=33337
Unit Lesson Electronic Health Records Health information systems are filled with patient data. Without patient data, there would not be a need for health information systems. These data can take many forms, from a medical diagnosis to a therapeutic regimen or from a laboratory result to a personal food diary. Through electronic record keeping, healthcare providers and organizations are able to collect, organize, and analyze patient data to support and improve clinical decision-making and to deliver more timely and effective care. Patients, too, are enjoying greater
UNIT III STUDY GUIDE
Electronic Health Records
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access to their personal health data, leading them to take a more active role in their healthcare decisions (Thomas, 2006). Before the move to electronic technology, it could days to months in order to locate a medical record and to make copies. Now, with larger healthcare facilities with robust electronic technology, a patient can login and have access to his or her medical record with that facility at any given time. This can be very beneficial for the patient if he or she is moving to another state and needs to obtain past medical records. These records can consist of numerous files, which can be hard to fax and scan. With the use of the electronic system, healthcare professionals can access them quickly and print them easily. A variety of formats emerged for this electronic record keeping of patient data. The most prominent ones are known as the electronic health record (EHR), the electronic medical record (EMR), and the personal health record (PHR). These are important terms in the healthcare arena. In this unit, we explore the similarities, differences, and interrelationships among these three types of electronic record keeping. In addition, we cover the hardware, software, and personnel needed to support EMRs, EHRs, and PHRs, as well as the role of change management in the successful implementation of health information technology (Bowie & Green, 2016). Similarities, Differences, and Interrelationships of EHR, EMR, and PHR Electronic medical records (EMRs), electronic health records (EHRs), and personal health records (PHRs) are all digital approaches to recording information related to patient care. They all have the benefit of easy access to data, making it possible to provide quality care by healthcare professionals. EMRs and EHRs provide automation of care and decision support. EMRs have been described essentially as replacements for paper charts (Bowie & Green, 2016). They are often used in hospitals and outpatient settings and are encounter-based. EMRs include laboratory and imaging reports, consultations, history and physical reports, and prescriptions. The individual healthcare organization owns the EMRs (Bowie & Green, 2016). The movement of paper copies to electronic records makes it easier to gain access to the files. This saves numerous hours spent looking for a file that has been misplaced. Having more time allows more patient to physician contact, which can benefit the healthcare facility and the patient.
EHRs provide more detailed information about the patient that can come from multiple encounters at different locations and can span a lifetime. Data include demographics, medical diagnoses, medications, vital signs, immunizations, and progress notes, among others. EHRs can be owned by the patient or other stakeholders like hospitals, clinics, or insurance companies. Any person providing health support services to the patient can enter data into the EHR through an interface. The patient can also access this data. EHRs have added benefits for quality management, outcome reporting, and research (Hebda & Czar, 2009). Reporting outcomes means giving the end result. Paper files were not easy to access, easily lost, and did not allow for great
quality management. This has all changed with the use of electronic files, which makes it easier to gain access to files and manage these files. This increases management skills by allowing more time to focus on the needs of the patients. Repetitive data like frequent vital signs, hourly intake and output, and continuous fetal heart rate monitoring should not be included in EHRs as they can make them cumbersome. Such data should be stored separately with an interface to EHRs so they can be referred to as needed. Storing data separately helps healthcare professionals reach the information quicker. By eliminating paper medical records and the associated issues, patients and providers can benefit from EHRs. Research has proven that doctors’ offices can realize cost savings by reducing the pulling of paper charts and the use of transcription services (Bowie & Green, 2016). This can also have a financial effect for stakeholders by providing a return on investment. The quality of health care can be improved through the adoption and proper use of EHRs.
(Schweihofer, 2017)
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The EHRs support data collection, which can be used to show what care has worked well in the past and what has not. It also can be used with billing to see what type of payments are received quicker, how contact is made with the patient, and what seems to work well when it comes data collection for billing. Quality management is huge because it shows the management system quality when being used, for instance, if individuals using the system feel it is easier to maneuver and has higher quality. An outcome report displays the ending results, which shows the positive and negative consequences. Planning for resources is having a list of resources for different types of treatment. For example, when it comes to breast cancer, a nurse navigator will provide the individual with breast cancer resources. It can help with the planning for wigs, prescriptions, and medical bills. These collections of data can be used to further research and gain knowledge in other aspects of health care. For instance, this data can show how direct clinical care has taken place, such as the physician and patient contact. It is important for the patient to have contact with the physician. The challenge is to use the information appropriately by protecting the information and preventing individuals from gaining access to other patients’ information. The information can be used to discriminate against the human rights of the patient. The role of the healthcare manager is important in administering appropriate procedures during this process. PHRs, which are owned and controlled by patients, provide a central place to store heath information over a lifetime. Data contained in PHRs include a list of health problems, allergies, diagnostic tests, current medications, emergency contacts, and self-reported measures such as weight, blood glucose, and blood pressures. PHRs are Web-based and can be accessed by the patient or authorized persons from anywhere (Bowie & Green, 2016). This makes it easier to obtain the patient’s record at any time and at any place. PHRs are particularly beneficial to patients with chronic or multiple medical conditions. It helps them keep track of all their visits, allergies, and medications so they are able to provide this information to clinicians as needed. They can also use this to set and achieve personal health goals. Change Management The role of change management has been introduced in health care over the recent years. Change management includes the process to manage how people deal with changes, like the introduction of new technologies, in order to ensure successful implementation of the changes. This has played the biggest role in record keeping. There are change factors such as hardware, software, and personnel when it comes to EMRs, EHRs, and PHRs. Hardware is defined as the computers that are used to house the records that are being kept. The software includes the systems used to house the records. The personnel are the individuals that complete the duties on hand to make sure the records are kept successfully. This makes for a successful implementation of health information technology, which is needed with the advancement in health care. Most individuals do not easily adapt to change, and this can be hard at times when it comes to making rapid and huge changes in a small amount of time. Change management is put into place to make sure these changes are successful and items are completed in a timely manner. While some individuals are not open to change, with changes in technology and health information, adaption to the changes have to occur to stay up- to-date. Summary With the move from paper charts to the electronic system, both patients and healthcare professionals can have access to a patient’s medical record at any time. Patients can share previous diagnoses and methods of care with different healthcare professionals, particularly when moving to new cities. Healthcare professionals can have a reliable medical history of a patient. The three digital approaches to electronic records include EMRs, EHRs, and PHRs. EMRs (owned by the healthcare organization) include laboratory and imaging reports, consultations, history and physical reports, and prescriptions. EHRs provide more detailed information about the patient, including demographics, medical diagnoses, and medications. PHRs (owned and controlled by patients) include lists of health problems, allergies, diagnostic tests, and self-reported measures such as weight.
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References Bowie, M. J., & Green, M. A. (2016). Essentials of health information management: Principles and practices
(3rd ed.). Boston, MA: Cengage Learning. Hebda, T., & Czar, P. (2009). Handbook of informatics for nurses and healthcare professionals (4th ed.).
Upper Saddle River, NJ: Pearson. Schweihofer, S. [Stux[. (2017). ECG electrocardiogram medical 2270728 [Photograph]. Retrieved from
https://pixabay.com/en/ecg-electrocardiogram-medical-2270728/ Thomas, R. L. (2006). Learning the alphabet of healthcare IT. Healthcare Financial Management, 60(3), 100–
102. Retrieved from https://libraryresources.columbiasouthern.edu/login?url=http://search.proquest.com.libraryresources.c olumbiasouthern.edu/docview/196382662?accountid=33337
Suggested Reading Please click the link below to access the PowerPoint presentation, which accompanies the textbook reading assignment. Click here for the Chapter 5 PowerPoint presentation. Click here for the PDF version.