HealthCare Management

Samantha Romano

HIM 500: Healthcare Informatics

Module 3 Activity

1. What is an EHR?

a. An EHR is an Electronic Health Record. According to Green & Bowie (2016), it is “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization”. It is different than an electronic medical record because an EMR is only held within one health care organization (Green & Bowie, 2016). These automated record systems document patient care using a computer (Green & Bowie, 2016). EHRs were supported by President George W. Bush in 2004 to help improve care and to reduce medical mistakes and costs (Green & Bowie, 2016). EHRs can be found in all different kinds of facilities throughout healthcare but no two facilities have the same systems (Green & Bowie, 2016).

2. What types of information are found in an EHR?

a. Within an HER there is information about schedules, admissions, registration, discharges, finances, patient demographics, patient health background, patient insurance information, test (lab and radiology) results, pharmaceutical information, doctor’s or nurses notes, and any other important information that can help with the care of the patient (Green & Bowie, 2016).

3. Who manages an EHR?

a. EHR’s are managed by healthcare workers, both administrative and clinical. There is not only one specific person who handles the entire EHR (Green & Bowie, 2016). In my current place of work, there are a number of people who handle a patient’s EHR. The first person to work on it is whoever answers the phone to schedule their first visit, usually the front desk. Then it is handed off to the insurance specialist who will update the insurance information for the patient. During the patient’s first visit, they will fill out new patient forms (background information, health history) and functional outcome assessments which are added to the EHR. After they check in, I take them back to evaluate them before the doctor comes in. I go over their forms with them, take blood pressure and pulse, assess range of motion, ask any additional questions I need, answer any of their questions and input this information into the EHR. Then the doctor will come in and perform an exam which I enter into the EHR. After this visit, the front desk will update the financial information and collect payment which is all updated in the EHR. When the patient comes back, another staff member will input information about their visits and treatment into the EHR. The doctors will include information when they feel they need to as they look over the notes. As it is in our office, there are many organizations where a number of people will manage an EHR.

4. How is it used?

a. EHRs are used in a clinical and administrative way. Specific applications include: patient scheduling, admission, registration, business/financial functions, management applications, patient monitoring systems, pharmacy applications, laboratory applications, radiology applications, nursing applications, medical documentation applications, and patient access application (Green & Bowie, 2016). The EHRs are used with these applications and functions to help give the best patient care possible. It is easier with electronic records to find someone’s information, store it, and display it. An organization can also include medical records from other organizations or offices to help compile a full record for a patient.

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

a. An EHR can follow a patient to other health facilities and an electronic medical record is held specifically in one organization (Green & Bowie, 2016). The EHR collects, stores, and displays clinical information that can be organized and sent to other health care organizations (Green & Bowie, 2016).

Reference:

Green, M. A., & Bowie, M. J. (2016). Essentials of health information management: Principles and practices (3rd ed.). Clifton Park, NY: Cengage Custom. ISBN: 978-1-305-26541-7