Electronic Health Records Assignment
Electronic Health Records
Health Information Technology
As defined in McGonigle and Mastrian (2018) by the Health Information Technology for Economic and Clinical Health (HITECH) Act, Health information technology (HIT) is comprised of “hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by healthcare entities or patients for the electronic creation, maintenance, access, or exchange of health information” (p.149). HIT has been promoted as a key element in the National Quality Strategy (NQS) to achieve three aims: better care, affordable care, and healthy populations and communities.
Electronic Health Records
To improve the quality of care through HIT, electronic health record (EHR) system implementation has become a top priority in US hospitals and healthcare organizations, underpinned by national initiatives such as the Health Information Technology for Economic and Clinical Health (HITECH) Act and EHR incentive programs such as Meaningful Use (MU) (Centers for Medicare and Medicaid Services, 2013). Beyond the goal of stimulating the implementation of EHR systems, the MU initiative was developed as an incentive program to assure that EHRSs are used according to standards that achieve quality, safety, and efficiency measures (Centers for Medicare and Medicaid Services, 2013). We will learn more about MU later in this lesson. Electronic Health Records Assignment
Numerous terms have been used over the years to describe the concept of an EHR, leading to confusion about the definitions. EHR has been used as a generic term for all electronic healthcare records and the related systems and recently became the favored term for an individual’s lifetime computerized record. In most usage, the term EHR is used to mean both the displayed or printed record and the supporting software system (EHRS). A basic definition of an EHR is a database of an individual’s healthcare data during healthcare encounters. An EHRS is the database management software enabling the many functions needed to create and maintain an EHR. Another simple definition is that an EHR is comprised of any patient data stored in electronic form. Other, lengthier definitions build from this premise. Updates to the electronic record are restricted to authorized clinicians and staff. Patients may be shown data in an EHR but do not have control. The EHRS usually includes software to manage: a data repository (the EHR database), practitioner order entry (POE)—also known as computerized practitioner order entry (CPOE)—clinical decision support (CDS), and practitioner documentation.
One of the major potential benefits of electronic health information is the ability to engage patients in their care and provide venues to access caregivers virtually, using email and web platforms, providing ease and convenience to the patient. The healthcare sector is just beginning to realize the potential value of the large pools of de-identified data at its disposal. This aggregate data, also known as secondary or big data, can be used to improve care, discover patterns, reduce costs, support research, and identify and respond to consumer preferences. The process of tapping this data is known by many terms, such as analytics, data mining, knowledge discovery in data bases, or business intelligence. The result is that the analysis provided can support better and timelier decision making, decrease risks, and discover valuable insights if appropriate tools are used. Harper (2013) suggested improved staffing models based upon patient information as one potential application for nurses.
Electronic record systems are built around large databases that allow input, storage, and retrieval of specific data for use in a meaningful way that can support other functions, such as decision support, results reporting, and order entry. Clinical documentation and clinical messaging are other basic functions. Use and reuse of data relies upon the collection of structured data that follows a format that supports manipulation. Electronic Health Records Assignment
In the following activity you will be presented with a patient being interviewed by a nurse practitioner. You can download the SOAP Note TemplateLinks to an external site. to fill in as you follow along with the scenario.
Lower Back Pain
After completing the activity you can view the answer key here. Lower Back Pain Answer KeyLinks to an external site.
EHRs provide users with enhanced versions of the functionality found in traditional paper-based health records. The addition of computer technology and digital data improves and expands on the basic set of functions.
Current functionality includes:
- Point-of-care (POC) access by practitioners
- Support for multiple users to view data on same patient at the same time
- Results review (laboratory, pathology, imaging, notes, etc.)
- Quality metrics
- Electronic communication
- Order management
- Patient monitoring in real time
- Patient summary displays
- Patient support
- Medication administration record
- Population health.
- Bar code medication administration.
- External reference resources.
- Billing (Payne, 2016; Hydari, Telang, & Marella, 2015).
- Centers for Medicare and Medicaid Services. (2013). Meaningful use. Baltimore, MD: Centers for Medicare and Medicaid Services. Retrieved from www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Electronic Health Records Assignment
- Harper, E. M. (2013). The economic value of healthcare data. Nursing Administrator Quarterly, 37(2), 105—108. https://journals.lww.com/naqjournal/Abstract/2013/04000/The_Economic_Value_of_Health_Care_Data.4.aspx
- Health Information Technology for Economic and Clinical Health Act. (2009). Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechact.pdf
- Hydari, M. Z., Telang, R., & Marella, W. M. (2015). Electronic health records and patient safety. Communications of the ACM, 58(11), 30-32.
- McBride, S. G., Tietze, M., & Fenton, M. V. (2013). Developing an applied informatics course for a Doctor of Nursing Practice program. Nurse Educator, 38(1), 37-42. https://pubmed.ncbi.nlm.nih.gov/23222633/
- Payne, T. H. (2016). The electronic health record as a catalyst for quality improvement in patient care. Heart, 102(22), 1782. doi: http://dx.doi.org.proxy.chamberlain.edu:8080/10.1136/heartjnl-2015-308724
- Resnick, C. M., Meara, J. G., Peltzman, M., & Gilley, M. (2016). Meaningful use: A program in transition. Bulletin of the American College of Surgeons, 101(3), 10-16. https://bulletin.facs.org/2016/03/meaningful-use-a-program-in-transition
EHRs Benefits and Drawbacks
Preparing the Discussion
Post a written response in the discussion forum to EACH threaded discussion topic:
- As discussed in the lesson and assigned reading for this week, EHRs provide both benefits and drawbacks. Create a “Pros” versus “Cons” table and include at least 3 items for each list. Next to each item, provide a brief rationale as to why you selected to include it on the respective list.
- Refer to the Stage 3 objectives for Meaningful Use located in this week’s lesson under the heading Meaningful Use and the HITECH Act. Select two objectives to research further. In your own words, provide a brief discussion as to how the objective may impact your role as an APN in clinical practice.
Adhere to the following guidelines regarding quality for the threaded discussions in Canvas:
- Application of Course Knowledge: Demonstrate the ability to analyze, synthesize, and/or apply principles and concepts learned in the course lesson and outside readings.
- Scholarliness and Scholarly Sources: Demonstrates achievement of scholarly inquiry for professional and academic decisions using valid, relevant, and reliable outside scholarly source to contribute to the discussion thread. Electronic Health Records Assignment
- Writing Mechanics: Grammar, spelling, syntax, and punctuation are accurate. In-text and reference citations should be formatted using correct APA guidelines.
- Direct Quotes: Good writing calls for the limited use of direct quotes. Direct quotes in discussions are to be limited to one short quotation (not to exceed 15 words). The quote must add substantively to the discussion. Points will be deducted under the grammar, syntax, APA category.
For each threaded discussion per week, the student will select no less than TWO scholarly sources to support the initial discussion post.
Scholarly Sources: Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are NOT considered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal. You are encouraged to use the Chamberlain library and search one of the available databases for a peer-reviewed journal article. The following sources should not be used: Wikipedia, Wikis, or blogs. These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality. For example, the American Heart Association is a .com site with scholarship and quality. It is the responsibility of the student to determine the scholarship and quality of any .com site. Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years. Instructor permission must be obtained BEFORE the assignment is due if using a source that is older than 5 years. Electronic Health Records Assignment