Electronic Medical Record (EMR)

With the advancement in technology, there has been a shift in the in the healthcare sector from paper-related documentation towards electronic recording. Therefore, electronic medical records are majorly used in specialty offices with physicians. The information contained in the electronic medical records includes medical history, physical notes and consults from providers and other physicians ( Rizer, Kaufman, Sieck, Hefner, & McAlearney, 2015) . Besides, EMR contains information regarding medications and immunization history including potential allergies. In general, the information in the EMR is classified into the Personally Identifiable Information (PII) that is used for identity purposes such as name and address while the Protected Health Information (PHI) focuses on a person’s health status, the underlying healthcare and payment. 

Uses of EMR 

Electronic medical records play a vital role in health care delivery. Particularly, EMR has greatly advanced the level of healthcare information by availing real-time information to clinicians thus improving the quality of decision making process with the patient (Aldosari, 2017).Contrary to the traditional paperwork recording, EMR bears the advantage of reduced medical errors that were initially attributed to factors such as ineligible handwritings, unnecessary duplications among other procedural errors. Besides, due to the underlying software’s ability to link various healthcare disciplines, ordering of tests, diagnosis, medication and inbuilt billing systems provides evidence –based practice information to assist the staff in fostering quality healthcare 

Documentation styles 

As an essential element of the electronic health record (EHR), physicians interact with the electronic medical records through various documentation styles. Dictation, free text and structured documentation are the three predominant documentation styles that are applied in practice (Vuokko, Mäkelä-Bengs, Hyppönen, Lindqvist, & Doupi, 2017). Arguably, the choice of documentation styles determines the quality of care. Research indicates that physicians who use structured documentation style while interacting with patients paid more attention to coded data lading to meaningful interactions and improved quality of care as compared to the free text and dictation modes. 

Implementation of EMR 

Implementation of EMR faces various challenges that relates to organizational and individual barriers. Rizer et al (2015) highlights various lessons learnt from the implementation of electronic medical records in an institution’s medical centre. Apparently, implementation of EMR require training of personnel and in some instances, organization require structural changes. Such structural elements and concerns of loss of productivity contribute to the reluctance and unwillingness in implementing electronic medical record. In spite of the emerging challenges, Rizer et al (2015) points out that the successful implementation of the electronic medical record in the large Midwest academic center was attributed to training, leadership, initial approach, optimization and support. 

Compliance Concerns 

Maintaining patient’s privacy aligns with the regulatory measures of privacy laws In particular, the Health Insurance Portability and Accountability act (HIPAA) was enacted in 1996 to protect the privacy of both the patient’s Protected Health Information and the Personal Health Information. In achieving the privacy goal, the Act establishes standards for authentication, access, storage and transmission of electronic medical records as well enforcing tighter restrictions for health care organizations in an attempt to manage the growing challenge of electronic threat to patient privacy (Sher,Talley,Yang & Kuo, 2017) . Non-compliance and violation of the stipulated regulations results in heavy fines especially within the contexts of certain types of electronic medical records such as the personal health record. 

Also, implementation of electronic medical records in healthcare corresponds to the requirements of the patient Protection and Affordable Care Act. The enacting of the Affordable Care Act resulted in a regulatory overhaul of the healthcare industry regarding emphasis on quality rather quantity (Sher et al., 2017). The provision of allocating Federal Incentives to healthcare organizations that implement electronic health records is a compliance factor that has greatly contributed to the massive adoption of electronic medical records. 

References 

Aldosari, B. (2017). Patients' safety in the era of EMR/EHR automation.  Informatics in Medicine Unlocked ,  9 , 230-233. 

Rizer, M. K., Kaufman, B., Sieck, C. J., Hefner, J. L., & McAlearney, A. S. (2015). Top 10 lessons learned from electronic medical record implementation in a large academic medical center. Perspectives in health information management , 12 (Summer). 

Sher, M. L., Talley, P. C., Yang, C. W., & Kuo, K. M. (2017). Compliance with electronic medical records privacy policy: An empirical investigation of hospital information technology staff.  INQUIRY: The Journal of Health Care Organization, Provision, and Financing ,  54 , 0046958017711759. 

Vuokko, R., Mäkelä-Bengs, P., Hyppönen, H., Lindqvist, M., & Doupi, P. (2017). Impacts of structuring the electronic health record: Results of a systematic literature review from the perspective of secondary use of patient data. International journal of medical informatics , 97 , 293-303.