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| 1. Paper-based medical records are no longer adequate. Individuals are more likely
to be treated by multiple providers in multiple facilities. To receive safe and effective
care, all providers need access to information in the patient's health record. This is not
possible with paper records. Many medical errors are a result of misplaced or lost medical
records and handwriting errors, particularly in prescriptions for medication. The cost of
health care is rising, and a significant amount of money is spent on administrative
processes still based on paper record-keeping.2. Medical liability premiums for health care providers have become more costly,
causing some doctors to leave the field. Corporations that provide health insurance
coverage to their employees are finding it more difficult to pay for these benefits, and
workers are being asked to pay more of the cost. 3. The federal government has played a significant role in bringing about changes
in the health care system. HIPAA legislation passed in 1996 established standards that
made it possible for insurance claims to be submitted electronically in a common format.
HIPAA also set standards for ensuring the privacy and security of personal health
information. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
encourages the use of electronic prescribing technology. In 2004, President George W. Bush
set a goal of establishing electronic health records for all Americans by the year 2014.
4. Electronic medical records are computerized versions of paper charts. They are
created and maintained by a single provider. Electronic health records are a computerized
lifelong health care record that includes information from multiple providers and
facilities. The information in the record is shared among providers treating the patient.
Electronic health records are used by health care professionals. Personal health records
are online files created and maintained by individuals. They contain information such as
current medications, allergies, health insurance details, medical history, and test
results. 5. Medical records in acute care settings focus on short-term events, while
records in ambulatory care settings track a person's symptoms, diagnoses, and treatment
over time. Acute care records include admission and discharge notes, which are not part of
an ambulatory care record. A major part of an ambulatory care record is the physician's
notes created during a patient encounter. 6. The eight core functions of an electronic health record are: 1. Health information and data elements 2. Results management 3. Order management 4. Decision support 5. Electronic communication and connectivity 6. Patient support 7. Administrative support 8. Population reporting and management 7. Electronic health records offer a number of advantages when compared with paper records. These advantages include a reduction in the number of medical errors, a higher quality of care for patients, and time and cost savings due to increased efficiency and productivity. 8. Electronic health records are not in widespread use today for a number of reasons: the cost of implementation, the lack of standards, a significant learning curve for staff members, workflow changes, and privacy and security risks to personal health information. 9. Students entering the field of health information technology may choose from a number of specialties, including medical record coder/abstractor, discharge analyst (acute care), tumor registrar, and quality analyst. |