An Electronic Health Record (EHR), also known as Electronic Medical Records (EMR) is an automated, online medical record where patient’s medical information is keyed in by eligible providers (EP) such as nurses or physicians. Through the utilization of encryption software as well as approved mail clients, EHR’s allow EP’s to chart all information regarding patients over time, making them a more effective way compared to paper records. An EHR contains data regarding the patient’s prescriptions, diagnosis, vitals, immunization status, medical history, surgical notes, and the information can be shared across different health care settings. EHRs are considered to be the modern health information technology that aid medical professionals in improving the quality and safety of care. The basic components of an EHR according to 75Health (2017), include clinical, laboratory, radiology, patient-management, and billing.
Clinical Component
There are multiple sub-components housed under the clinical component. They include The computerized physician order entry (CPOE) used for feeding patients’ needs directly into the computer, electronic documentation where such notes as medical history, consultation, and operative notes are documented, the pharmacy component which is used for filling prescriptions and maintain a drug formulary. Finally, the nursing component enables the collection of crucial patient data such as vital signs.
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Laboratory Component
The laboratory component is used as a hub for all laboratory results and integration with billing. The lab component is therefore divided into two sub-components, one which focuses on the patient’s lab results and the other one on integration with billing, orders and lab machines.
Radiology System Component
This component is crucial for the radiology department as it uses it to tie together a patient’s radiology information and images. The functions under this component include patient tracking, scheduling, results reporting and image tracking, This component works alongside the Picture Archiving Communications systems responsible for digital radiography studies. Together, the two are useful for managing patient workflow, ordering procedures, images, and results.
Patient Management Component
This component is essential for the functionality of patient registration, admission, and discharge. It is a Key component of the EHR as it includes crucial patient information such as contacts, insurance details, and demographics.
Billing Component
This section contains all the charges generated during the provision of care to the patient. AL claims are generated from the charges and submitted to insurance providers.
More healthcare facilities are switching from paper charts to electronic medical records. This is because most of them realize that the benefits for the EP’s and the patients will increase. Some of the attributes of Electronic Health Records Include:
EHR provide secure, reliable and real-time access to patients health record
The system captures and manages episodic and longitudinal electronic health record information.
EHR functions as the primary source of information to EP’s during the provision of patient care
It assists with the planning of work as well as the delivery of evidence-based care to individual and patients.
EHR capture relevant data that is used continuously for improvement of quality, risk management, resource planning, and performance management.
Supports medical reimbursement by capturing patient-related data, the information also aids in support of clinical research and public health reporting
The system actively supports clinical trials and evidence-based research
Increased Quality of Care
The use of EHR’s enables the real-time exchange of patient health data. The use of accurate and well-updated information during treatment leads to an increased quality of care; this is because the chances of errors are reduced and the diagnosis is better (Raposo, 2015) . EHR’s can send automatic reminders for screenings as well as preventive visits; this helps a patient better manage their condition and participate more in their healthcare. Through electronic prescribing, physicians can communicate directly with pharmacists, therefore, reducing errors as well as saving time by eliminating lost prescriptions. The safety of patients is also improved since electronic prescribing checks for potentially dangerous drug interactions.
Increased Efficiency
EHR’s enable centralized chart management and quicker access to information regardless of location, therefore, proving to be more efficient than paperwork. Communication with other physicians and parties involved is also much faster and easily traceable. This helps cut down on lost message as well as follow-up calls. The system features lead to much time been saved and higher productivity.
Financial Incentives
The process of setting up an EHR system can be very costly for any health service providers; however financial incentives have been made available to help firms recoup their investments. According to USFHealth (2017), programs such as Medicare EHR incentive program and Medicaid, HER incentive programs provide incentives to eligible EP’s for the adoption and meaningful use of HER technology.
Accessibility
Trying to obtain relevant information in paperwork especially where the details are many can be very tiresome. EHR’s allow for easy access f a patient’s information including their medical history. The system contains all the information required for providing care to a patient. Therefore the provision of care to a patient is made more quickly and efficiently.
References
75Health. (2017, May 16). What Components Constitute an Electronic Health Record? – 75Health. Retrieved April 10, 2019, from http://blog.75health.com/what-components-constitute-an-electronic-health-record/
Raposo, V. L. (2015). Electronic health records: Is it a risk worth taking in healthcare delivery? GMS Health Technol Assess , 11 . doi: 10.3205/hta000123
USFHealth. (2017, July 21). Benefits of Electronic Health Records. Retrieved April 10, 2019, from https://www.usfhealthonline.com/resources/healthcare/benefits-of-ehr/
