Electronic Health Record

Gone are the days when all medical documentation was done using a pen and paper. Thanks to advancements in technology, there are modernized ways to gather, store, and transmit information more efficiently. The paper charting method has been shifted to a rather digital version of documentation known as the Electronic Health Record (EHR). The EHR provides a real-time and secure way to manage patient medical records. “Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports,” (Habda & Czar, 2013). The information gathered using an EHR provides a more broader outlook on the care each patient. With the use of an EHR, patient
data can be transmitted from one facility to the next with just the click of a button. This allows an individual’s medical information to be shared to all necessary providers and organization such as schools, labs, pharmacy’s, specialists, and more. The integration of the electronic health record into hospital and clinical settings has provided both pro’s and con’s regarding its’ use in those facilities. One of the pro’s for using an electronic health record is that it allows the providers to have more one-on-one time to interact with their patients without spending so much time on the actual documentation process.
Providers now have a quick access to view up-to-date patient information which allows them to perform more coordinated patient care. It also provides the patient’s with access to their own health records. Patient’s are now able to input information regarding their hospital visit and other details that are normally filled out on various forms prior to being seen by a provider. These advancements allow patients to be diagnosed more effectively which in turn leads to a reduction in medical errors and provides overall safer patient
care. Some clinics and other healthcare facilities have adopted the use of the EHR and noticed a big improvement in their patient care. This adoption allows the staff to be more efficient in terms of communication because all data can be transmitted electronically which allows multiple users to view the patient data at once rather than searching through binders for that information. These electronic records come in handy when used in emergent situation such as receiving a patient with a myocardial infarction and needing to transmit information such as an EKG and radiologic results to consulting doctors. Not only that, but we live in a world full of natural disasters, some predictable, some aren’t. With that being said, it is important to be able to maintain and keep track of patient medical information in the event of a catastrophic disaster that would typically destroy paper documents. Having access to digital copies of these records allow those providers caring for patients displaced from these disasters to have their records easily accessible for a more efficient care. One disadvantage of using electronic health records are possible security issues.
When information shifts to an online database, it then poses a risk for hackers to break into. This leads to a breech in patient privacy which can cause major concerns for patients. Another downfall with implementing the EHR into hospital and clinical settings include its’ increased cost to implement that system. When it comes to shifting from using natural resources to more technological resources, an increased cost should be expected since now maintenance, training and other aspects of transitioning to digital usage has to be taken into account. I do however believe the implementation of the EHR has had many positive effects on the overall hospital experience despite the cons that may accompany its' use. I can’t imagine having to quickly jot everything down in a patient’s chart and struggle to interpret various providers handwritings for their prescribed orders. One way that hospitals are held accountable for their proper use of the electronic health record is through the achievement of meaningful
use. Meaningful use is a set of guidelines used to make sure electronic health records are of any use in terms of its’ ability to provide significant results in the healthcare environment. When these guidelines are achieved, hospitals and other eligible entities are able to qualify for Medicare and Medicaid services. Its’ goal is to enhance the clinical experience, reduce health disparities, allow patient’s and family members to be more engaged in their health, all while maintaining a private and secure health record. Meaningful use improves the coordination of care by sustaining these guidelines and empowering individuals to become more in tune with their health. The integration of the electronic health record and meaningful use in hospitals, physician offices and other settings has provided both pro’s and con’s regarding its’ use in those facilities. The advancement of the charting process which led to the adaptation of the electronic health record has transformed the healthcare field. This new method of charting has improved many aspects of patient care such as enhancing methods of communication, providing better patient-centered care, and improving patient education and safety. In the healthcare world, the implementation of the EHR can help patients become more hands-on with their care. They can keep track of their medication regimen and it can assist nurses in researching information on the most recent evidence-based practice topics. Regardless of the increase cost of switching to an electronic health record system, I think they can have positive effects in terms of improving the utility of healthcare information systems. Despite the pros and cons of the EHR, the overall benefit it has provided the healthcare system with in regards to a more efficient method of providing patient care is very significant.