Electronic Medical Records (EMRS) /PHE3040 Week 5 Discussion

Electronic Medical Records (EMRS) /PHE3040 Week 5 Discussion

Electronic Medical Records (EMRS)

Electronic medical records (EMRs) document the healthcare provided to the patient using both unstructured clinical notes and structured data. Typically, these records are large, containing hundreds of documents about a single patient. To navigate the vast amounts of information about a patient, current EMR applications available to physicians either attempt to proactively summarize important patient information or they provide a more traditional search service that retrieves notes “relevant” to a given query. However, it may be possible to much more precisely (and automatically) answer very specific questions about the patient’s health, by providing short answers to natural language questions – perhaps supported by evidence. For e.g., “Why was the patient prescribed a certain drug?” or “Were there any complications of the patient's heart surgery?” could be answered with very specific phrases or passages from the EMR.

Discuss one benefit of using electronic medical records.

Discuss one issue/problem that could be caused using electronic medical records that would not be an issue/problem with paper record?

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Components of An information system

HIM professionals are conventionally the business managers and custodians of data and information in healthcare.

An information system consists of four interrelated components—data, information technology, process, and users.  HIM professionals' traditional job roles make them the experts in managing data and processes in an information system. With the digitizing of information systems in healthcare organizations, the roles of HIM professionals have expanded into information technology (IT) and user support, which usually are the functions of IT supporting services. HIM professionals' training and experience in the intersection of clinical and management sciences as well as their knowledge about data quality equip them with the capability to maintain the integrity and accessibility of health information, although they may not necessarily have the particular skills to support technical operations of a health information system. For example, HIM educational programs usually do not provide courses in computer science theories such as algorithms or formal methods.

The delineating line between traditional HIM and HIT professionals has been blurred by the convergence of their functions and reporting structures in the electronic healthcare environment. Three areas of expertise have become the point of the convergence: 1) maintaining confidentiality and security of patient information, 2) using and maintaining data and information, and 3) terminology asset management.

Due to the convergence of the functions between HIM and HIT, professionals from both groups can work together to take a wide range of roles in the electronic healthcare environment.  These roles include joint educator or trainer, project manager, work flow analyst for clinical systems, privacy and security officer, EHR program manager, and data management and analytics professional. The authors claim that HIM professionals are no longer found exclusively in the record room as more HIM professionals step up to take information resource management roles in an electronic healthcare environment.

Electronic Medical Record

An electronic medical record (EMR) contains the standard medical and clinical data gathered in one provider’s office. Electronic health records (EHRs) go beyond the data collected in the provider’s office and include a more comprehensive patient history.

For example, EHRs are designed to contain and share information from all providers involved in a patient’s care. EHR data can be created, managed, and consulted by authorized providers and staff from across more than one health care organization.

Unlike EMRs, EHRs also allow a patient’s health record to move with them—to other health care providers, specialists, hospitals, nursing homes, and even across states.

An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment.

Benefits of Electronic Medical Records

An EMR is more beneficial than paper records because it allows providers to:

· Track data over time

· Identify patients who are due for preventive visits and screenings

· Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings

· Improve overall quality of care in a practice

The information stored in EMRs is not easily shared with providers outside of a practice. A patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team.

Health care Environment

Health care professionals’ practice in an environment that is complex, with many regulations, laws and standards of practice. Performing an abortion is legal but may not be considered ethical by other health care professionals or members of the public at large. Other ethical dilemmas arise at the end of life, when a decision must be made to turn off life-support machines and allow death to occur. Other common ethical issues a health care professional might face are confidentiality, relationships with patients and matters related to consent, especially in the treatment of minors.

 Confidentiality is both an ethical and a legal issue. Keeping information about a patient confidential is a way of showing respect for the person’s autonomy; releasing information can damage the patient. There are also specific laws regarding the release of information under the Health Insurance Portability and Accountability Act, or HIPAA. The laws define exactly what information can be released and to whom.

 Relationships with patients, particularly sexual relationships, are forbidden by both the medical and nursing code of ethics. Such actions are considered serious misconduct and can result in expulsion from the profession and losing the license to practice. A sexual relationship is considered to be an abuse of power on the part of the physician or nurse, as patients are dependent and vulnerable.

 Health care practitioners of all sorts face the risk of being sued for malpractice. A lawsuit may be brought from an injury related to surgery, defective equipment or medical products, care that was omitted or a deliberate act that caused harm to a patient. The risk of litigation is such that many health care professionals’ practice what is called defensive medicine -- for example, ordering a test or performing a procedure primarily to ensure that the patient cannot allege negligence.