Discuss the difference between an electronic health record and an electronic medical record. Since there is an increase in adopting electronic medical records, why is it important to keep track of the location of paper health records and why is this step unnecessary in an electronic record system?
Post #1 In healthcare, as technology expands, the digitization of records increases. There are two types of electronic records one being electronic health record and the other being electronic medical record. Though they sound similar, they are actually different and serve different purposes. An Electronic Medical Record (EMR) is a copy of the patient’s chart which contains medical and treatment history from one specific practice. This record usually does not transfer if a patient were to switch doctors or move. There was a mandate put into place for electronic medical records in order to increase accuracy and accessibility for health records. The HITECH tries to encourage healthcare facilities to implement programs for EMR’s. Within the Act there are regulations and guidelines that must be met. Without the use of an EMR system, healthcare facilities will not be eligible to utilize EHR technology. In order to comply with the rules in place the CDC created five pillars of health to maintain. These include improving quality and safety that reduce disparities, get the families and patients involved in their healthcare, improve care coordination, improve public health, and lastly ensure privacy and security (Daughtery, 2020). This mandate has been able to improve the field of health informatics along the way. EMR’s are very valuable compared to paper records that enable providers to track patient data, improve screen processes, and improve the overall health care quality given (What are the Differences, 2019). As technology advances the use of paper records has been depleted but the importance of keeping them secure is still relevant. Most electronic health records are compiled of both digital and paper data (Evans,2016). Keeping track of the paper files ensures patient confidentiality and security of their files. It also provides back up information if a computer software dies or malfunctions. Having access to paper medical files is still important even as most healthcare facilities switch to an online database of filing. Because of the costly transition to completely online data, EHR’s work as a complement to paper medical records. An EHR is slightly different and holds a more holistic approach to patient care. An electronic health record follows the patient wherever they are being treated. It gives a wider range of access for all clinical staff and physicians. It also increases the incentives provided by CMS (Understanding EMR, n.d). An EHR goes beyond the transitional data collected giving a broader scope of patient care. EHR’s are a huge aspect of health IT. They contain medical history, medications, treatment plans and so forth. It also allows access to tools that help make health decisions. Health information can be easily managed in a digital format. Utilizing these systems creates an efficient health IT infrastructure. EHR’s are used to share information between healthcare providers and organizations. Within the EHR infrastructure, keeping access to paper files can be seen as unnecessary however. Technology has rapidly changed the dynamic of healthcare forever with smartphones, tablets, and web devices that have made it easier to access patient health records. The flow of information is more effortless but yet provides higher quality of care to patients. At the end of the day quality healthcare is the priority whether it’s through digitization of health records, or chicken scratch on a notepad. The Bible talks about healing and care in Jeremiah 30:17. “For I will restore health to you, and your wounds I will heal, declares the Lord, because they have called you an outcast: ‘It is Zion, for whom no one cares!’’ Ultimately, the results of the care matter more than the approach taken to get to the end game. Healthcare providers can find rest in God during uncertain times and know he will heal us of our iniquities.
Post #2 Introduction
Health records have been present in health care for decades. Without documentation of care provided to patients, it would be difficult to continually treat the same patient. The health records can provide the story of a patient when it is viewed by the next care provider. Shanholtzer and Ozanich (2016) define a health record as “documents that accurately identify the patient and completely explain the reason for the patient’s visit, including the principal or primary reason for the encounter” (p. 33). Health records contain documents of other co-existing diagnoses, procedures, family history, and treatment results. A care provider should be able to look at a patient’s completed health record or chart and know how to proceed with care.
Health Record Formats
Paper records have been the primary format of collecting and maintaining health records up until roughly two decades ago. Health records would be documented during a patient’s stay or office visit, compiled, completed, and then brought to a file room to be stored. As technology has advanced, the disadvantages of paper records have become more relevant. Two major disadvantages include access being limited to one healthcare professional at a time, and the likelihood the documents are easily misplaced (Shanholtzer & Ozanich, 2016). Technology advancements have aided in the ability to diminish the disadvantages of paper records by introducing electronic health records.
Electronic health records (EHRs) and electronic medical records (EMRs) are terms often used interchangeably but have differences (Shanholtzer & Ozanich, 2016). EMRs are described by the Office of the National Coordinator for Health IT (ONC) as digitized paper charts in health care offices and hospitals. EMRs contain the information within the specific clinic that has the records. ONC defines EHRs as “built to go beyond standard clinical data collected in a provider’s office and inclusive of a broader view of patient’s care” (Shanholtzer & Ozanich, p. 36, 2016). EHRs are unique because they are designed to be exchanged between multiple health care providers from different health organizations involved in the patient’s care. This can include multiple facilities, labs, long-term care, etc. EHRs meet the certification requirements set by Meaningful Use while EMRs do not meet the requirements. Just are paper formats being once the most common, EMRs were introduced, and now EHRs have begun to replace both as health organizations continue to adopt EHRs. An advantage to the electronic format is the ability to quickly access the needed information, whereas paper formats cause greater difficulties because files can be lost and misplaced.
Practical Application
I currently work in a hospital near where I live and constantly document in patient charts. Meals, vitals, diagnosis, interpreter services, and many other aspects are documented in charts. The ease and quickness of EHRs is a tremendous advantage to documentation because each step the documenter makes is recorded and can be shared with all involved in the patient’s care. Akhu-Zaheya, Al-Maaitah, and Bany Hani’s (2018) study evaluated paper-based health records versus electronic-based health records for nurses. Nurses are one of the most frequent documenters in charts because they spend the most time with the patient. Paper-based documentation has been viewed as unable to meet the requirements of quality documentation, communication between providers, time-consuming, and inaccurate (Akhu-Zaheya et al., 2018). A study by Perry et al. (2014) evaluated the use of paper-based records versus electronic-based in an emergency room that requires quick and accurate documentation. The study revealed that physicians had difficulty accepting the use of EHRs because of poor education but did state the importance of the time-saving that EHRs introduce. EHRs allow for health care organizations to become more diligent with documentation. Proverbs 21:5 tells us that the diligent will profit (New King James Version Bible, 1798/1982). EHRs offer an improved system for health care that provides diligence resulting in better quality care and success of the organization.
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