Electronic Health Records
Since the introduction of electronic health records, the U.S. government, information systems developers and associations of healthcare providers have worked toward establishing a uniform, integrated system of electronic health records. This collaboration is designed to significantly enhance patient safety and treatment, as well as effectively assist in the management of public health issues such as disease. While some health practitioners report difficulties in dealing with electronic health records, it appears that continued efforts and refinements are gradually solving problems of computerization and are improving healthcare.
Characteristics and Components of Efficient EHR
In 2003, the Institute of Medicine released a report called Key capabilities of an electronic health record system. In this consensus report, the Institute stated that an electronic health records system should consist of:
"a longitudinal collection of electronic health information for and about persons;
2. [immediate] electronic access to person- and population-level information by authorized users;
3. Provision of knowledge and decision-support systems [that enhance the quality, safety, and efficiency of patient care] and support for efficient processes for health care delivery" (Institute of Medicine, 2003, p. 4).
Flowing from these basic ideas, the Institute identified 8 "core care delivery functions" (Institute of Medicine, 2003, p. 7), later adopted within the 2004 National Research Council's Patient safety: Achieving a new standard for care (National Research Council, 2004). Addressing many health-related issues, including electronic health records, the Council addressed the issues of: continuity of a patient's care among multiple providers; effective communication between the patient and his/her healthcare providers, and among multiple providers; coordination of care due to multiple healthcare professionals' comprehensive and easy access to the patient's history and current treatment(s); accountability among healthcare professionals for accurate data collection, entry of data into the electronic systems and compliance with reporting requirements; basic categories of vital information that should be included in the electronic records system.
The 8 core functions are:
1. Health Information and Data: In order to make well-grounded treatment...
Result Management: In order to optimize the efficiency of patient care and enhance the patient's safety, all healthcare professionals can promptly receive and review all test results;
3. Order Management: In order to make orders more legible and avoid repetition, thus making orders speedier, prescriptions, tests and various healthcare treatments are entered into a computerized system;
4. Decision Support: To comply with "best clinical practices" for screenings, prevention and drug interactions, electronic records can automatically issue notices, cues and warnings;
5. Electronic Communication and Connectivity: In order to enhance care continuity, increase the speed and accuracy of diagnoses and avoid negative impacts on patient care, the electronic system increases the effectiveness, security and accessibility of medical records, information shared between healthcare professionals and data obtained directly from patients;
6. Patient Support: Patients with chronic illnesses requiring self-monitoring and self-testing can easily review their records, education about their illnesses, and other tools that help them deal as effectively as possible with their diseases;
7. Administrative Processes: Hospitals and clinics can enhance their scheduling, efficiency and the timeliness of their services through computerized administrative systems;
8. Reporting: Healthcare professionals can comply more efficiently with the reporting requirements of the federal government, applicable state government and private associations, which also assist in federal, state and private examination and oversight regarding public safety and disease issues.
Barriers and Issues
As multi-disciplinary professionals work to develop and refine electronic health records systems, they have encountered and defined some significant barriers and issues. Barriers include: technical concerns regarding quality, usefulness and lack of integration with other systems; costs of hardware, software, and related information technology costs; resources concerns about staff training, resistance to use of the systems, required work changes; concerns about certifications, security, ethics, privacy and…
