Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Satisfaction of health‐care providers with electronic health records and perceived barriers to its implementation in the United Arab Emirates

The integration of electronic health records (EHRs) has shown promise in improving health‐care quality. In the United Arab Emirates, EHRs have been recently adopted to improve the quality and safety of patient care. A cross‐sectional survey of 680 health‐care providers (HCPs) was conducted to assess the satisfaction of HCPs in the United Arab Emirates with EHRs' impact on access/viewing, documentation and medication administration and to explore the barriers encountered in their use. Data were collected over 6 months from April to September 2014. High overall satisfaction with EHRs was reported by HCPs, suggesting their acceptance. Physicians reported the greatest overall satisfaction with EHRs, although nurses showed significantly higher satisfaction with the impact on medication administration compared with other HCPs. The most significant barriers reported by nurses were lack of belief in the value of EHRs for patients and lack of adequate computer skills. Given the large investment in technology, additional research is necessary to promote the full utilization of EHRs. Nurses need to be aware of the value of EHRs for patient care and be involved in all stages of EHR implementations to maximize its meaningful use for better clinical outcomes.     

Health information technology and nursing

OVERVIEW: Health information technology (HIT) is a central aspect of current U.S. government efforts to reduce costs and improve the efficiency and safety of the health care system. A federal push to implement and enhance electronic health records (EHRs) has been supported by billions of dollars earmarked in the Health Information Technology for Economic and Clinical Health Act, passed as part of the 2009 American Recovery and Reinvestment Act. The goal has been to lay the groundwork for a HIT system that enables a more reliable exchange of information among practitioners and patients and significant improvements in the way care is delivered.But what does this really mean for nurses? This article is the first in a series on HIT and nursing and will examine the federal policies behind efforts to expand the use of this technology as well as the implications for nurses. Subsequent articles will take a closer look at the use of EHRs to improve patient safety and quality of care, and the important role nurses are playing-and could play-in this system-wide initiative.     

Nurse Practitioners and Meaningful Use: Transforming Health Care

This article describes how the adoption of electronic health records (EHRs) and the achievement of Meaningful Use requirements by nurse practitioners (NPs) can transform patient care. By implementing EHRs, NPs can improve the quality and consistency of care while simultaneously reducing health-care costs. This article provides insight into considerations for NP participation in the EHR Incentive Program. It includes a case study focusing on one NP’s experience with the program, who sought to improve the quality of patient care, safety, and satisfaction through health information technology, along with the challenging yet rewarding journey to practice transformation.     

Electronic health records: a primer for practicing physicians

Electronic health records (EHRs) offer a number of advantages over the old paper record. They have the potential to improve the quality of patient care, reduce the cost of health care, and expedite the transfer of information. Yet fewer than 20% of hospitals and physician practices now use them. We discuss the advantages of EHRs, reasons for adopting this system, current barriers to the adoption of EHRs, and issues to consider when choosing a system.     

Possibilities and Implications of Using the ICF and Other Vocabulary Standards in Electronic Health Records

There is now widespread recognition of the powerful potential of electronic health record (EHR) systems to improve the health‐care delivery system. The benefits of EHRs grow even larger when the health data within their purview are seamlessly shared, aggregated and processed across different providers, settings and institutions. Yet, the plethora of idiosyncratic conventions for identifying the same clinical content in different information systems is a fundamental barrier to fully leveraging the potential of EHRs. Only by adopting vocabulary standards that provide the lingua franca across these local dialects can computers efficiently move, aggregate and use health data for decision support, outcomes management, quality reporting, research and many other purposes. In this regard, the International Classification of Functioning, Disability, and Health (ICF) is an important standard for physiotherapists because it provides a framework and standard language for describing health and health‐related states. However, physiotherapists and other health‐care professionals capture a wide range of data such as patient histories, clinical findings, tests and measurements, procedures, and so on, for which other vocabulary standards such as Logical Observation Identifiers Names and Codes and Systematized Nomenclature Of Medicine Clinical Terms are crucial for interoperable communication between different electronic systems. In this paper, we describe how the ICF and other internationally accepted vocabulary standards could advance physiotherapy practise and research by enabling data sharing and reuse by EHRs. We highlight how these different vocabulary standards fit together within a comprehensive record system, and how EHRs can make use of them, with a particular focus on enhancing decision‐making. By incorporating the ICF and other internationally accepted vocabulary standards into our clinical information systems, physiotherapists will be able to leverage the potent capabilities of EHRs and contribute our unique clinical perspective to other health‐care providers within the emerging electronic health information infrastructure. Copyright © 2013 John Wiley & Sons, Ltd.     

The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety

The aim of this study was to examine the effect of having a basic electronic health record (EHR) on nurse-assessed quality of care, including patient safety. Few large-scale studies have examined how adoption of EHRs may be associated with quality of care. A cross-sectional, secondary analysis of nurse and hospital survey data was conducted. The final sample included 16,352 nurses working in 316 hospitals in 4 states. Logistic regression models were used to evaluate the relationship between basic EHR adoption and nurse-assessed quality of care outcomes. Nurses working in hospitals with basic EHRs consistently reported that poor patient safety and other quality outcomes occurred less frequently than reported by nurses working in hospitals without an EHR. Our findings suggest that the implementation of a basic EHR may result in improved and more efficient nursing care, better care coordination, and patient safety.     

Electronic health records: use, barriers and satisfaction among physicians who care for black and Hispanic patients

Objectives  Electronic health records (EHRs) are a promising tool to improve the quality of health care, although it remains unclear who will benefit from this new technology. Given that a small group of providers care for most racial/ethnic minorities, we sought to determine whether minority-serving providers adopt EHR systems at comparable rates to other providers.
Methods  We used survey data from stratified random sample of all medical practices in Massachusetts in 2005. We determined rates of EHR adoption, perceived barriers to adoption, and satisfaction with EHR systems.
Results  Physicians who reported patient panels of more than 40% black or Hispanic had comparable levels of EHR adoption than other physicians (27.9% and 21.8%, respectively, P  = 0.46). Physicians from minority-serving practices identified financial and other barriers to implementing EHR systems at similar rates, although these physicians were less likely to be concerned with privacy and security concerns of EHRs (47.1% vs. 64.4%, P  = 0.01). Finally, physicians from high-minority practices had similar perceptions about the positive impact of EHRs on quality (73.7% vs. 76.6%, P  = 0.43) and costs (46.9% vs. 51.5%, P  = 0.17) of care.
Conclusions  In a state with a diverse minority population, we found no evidence that minority-serving providers had lower EHR adoption rates, faced different barriers to adoption or were less satisfied with EHRs. Given the importance of ensuring that minority-serving providers have equal access to EHR systems, we failed to find evidence of a new digital divide.     

Motivations and barriers to implementing electronic health records and ED information systems in Japan

Background

Although electronic health record systems (EHRs) and emergency department information systems (EDISs) enable safe, efficient, and high-quality care, these systems have not yet been studied well. Here, we assessed (1) the prevalence of EHRs and EDISs, (2) changes in efficiency in emergency medical practices after introducing EHR and EDIS, and (3) barriers to and expectations from the EHR-EDIS transition in EDs of medical facilities with EHRs in Japan.

Materials and methods

A survey regarding EHR (basic or comprehensive) and EDIS implementation was mailed to 466 hospitals. We examined the efficiency after EHR implementation and perceived barriers and expectations regarding the use of EDIS with existing EHRs. The survey was completed anonymously.

Results

Totally, 215 hospitals completed the survey (response rate, 46.1%), of which, 76.3% had basic EHRs, 4.2% had comprehensive EHRs, and 1.9% had EDISs. After introducing EHRs and EDISs, a reduction in the time required to access previous patient information and share patient information was noted, but no change was observed in the time required to produce medical records and the overall time for each medical care. For hospitals with EHRs, the most commonly cited barriers to EDIS implementation were inadequate funding for adoption and maintenance and potential adverse effects on workflow. The most desired function in the EHR-EDIS transition was establishing appropriate clinical guidelines for residents within their system.

Conclusion

To attract EDs to EDIS from EHR, systems focusing on decreasing the time required to produce medical records and establishing appropriate clinical guidelines for residents are required.     

Health information technology: transforming chronic disease management and care transitions

Adoption of health information technology (HIT) is a key effort in improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety.     

Out-of-Hospital Research in the Era of Electronic Health Records

Conducting out-of-hospital research is unique and challenging and requires tracking patients across multiple phases of care, using multiple sources of patient records and multiple hospitals. The logistics and strategies used for out-of-hospital research are distinct from other forms of clinical research. The increasing use of electronic health records (EHRs) by hospitals and emergency medical services (EMS) agencies presents a large opportunity for accelerating out-of-hospital research, as well as particular challenges. In this study, we describe seven key aspects of designing and implementing out-of-hospital research in the era of EHRs: (1) selection of research sites, (2) defining the patient population, (3) patient sampling and sample size calculations, (4) EMS data, (5) hospital selection, (6) handling missing data, and (7) statistical analysis. We use examples from a recent prospective out-of-hospital cohort study to illustrate these topics, including lessons learned.     

Meaningful Use of Electronic Health Records

The concerns on patient safety and quality improvement in health care are increasing. There is growing use of technology in health care, particularly use of the electronic health record (EHR). As this occurs, the health care system is transforming. The federal government has become involved in EHR implementation, encouraging improved health care. The Centers for Medicare & Medicaid Services are implementing the Meaningful Use (MU) Incentive Program for Medicare- and Medicaid-eligible providers. As EHR implementation and MU Programs grow, it is important for the nurse practitioner (NP) to be aware of the MU Program. As NPs become engaged in using EHRs, MU will have an impact on changing health care systems and implications related to clinical practice and improved outcomes.