Electronic
health record refers to a collection of health records belonging to patients
that are generated through any formal meeting in a health care centre.
Typically, EHR includes progress notes, medications, patient demographics,
laboratory data, vital signs, radiology reports and past medical history. System
must ensure such patients’ sensitive information are secure, ensure data
confidentiality, capable of working with other systems in sharing information
and most importantly, ensure performance of its function accurately (Ulmer, 2009).
Such tasks will make both patients and providers confident with the system.
It
depends on various things for one to be employed as a staff in a medical
centre. All these aims at keeping positive and efficient quality patient care.
In order to ensure quality is paramount, nursing and physicians need
present-day and latest records of a patient. This is more possible with EHR
since we expect the rate for information exchange to upsurge with the
introduction of this system. Nevertheless, the system ensures patient get the
best care by ensuring staff from other different medical centres are up to date
regarding the medical information of the patient through this coordinating
system (Moen, 2011).
This means there is the easy accessibility of patients’ medical information
from other centres or departments. If utilized well, the system can save or
change a lot of lives in the United States and around the world.
Certification
versus Gold Standards
The
two differs majorly in their purpose. Functional model like HL7 works as a gold
standard-it identifies functions that have to be contained in an electronic
health record system. In summary, it gives the description of whatever every
function ought to do without being compromised significantly from product or
market influences. This functional model
ensures standards are set high for HER system. This model ensures integrity by
detaching definition from current product development influences (Ulmer, 2009).
Consequently, this functional model clearly maintains that no product can meet
its full requirement today.
Essentially,
certification aims at bridging the gap between the current marketplace and the
gold standard. In ensuring products reach functional model gradually,
certification provides a clear road map. HL7 provides that EHR system recognize
and preserve a patient’s record. For
instance, in an event health information is incorrectly linked to a patient,
HER system shall be providing the ability to correctly associate it with the
right patient. Looking at it practically, few will debate that this system
should be equipped with a mechanism whereby it is possible for a clinician to
correct this errors; linking information that had been previously linked to a
wrong patient by the system to the right patient.
Rights
to Medical Records
Some
health care providers argue that system incompatibility cannot be an issue.
They have stood their grounds that their medical records are copyrighted
information hence it is difficult to share them with other medical care centres (Englebardt, 2002).
However, in passing Recovery Act, Congress made it clear that all patients have
got a right of obtaining information from their own records. It meant that the
records could be securely handled when moved to other health care centres where
they will be readily usable and readable.
Conclusion
Therefore,
there are some reasons for standardizing the health record systems. Decisively,
standardized records containing info about experiences of patients will come up
with vital info concerning what is working or what is not working in medicine.
This valuable information can be utilized by the nation in improving health
care drastically. Standardization will be instrumental in improving EHR systems
in coming years.
References
Moen, A. (2011). User Centred
Networked Health Care Proceedings of MIE 2011. Amsterdam: IOS Press.
Ulmer, C. (2009). Race,
ethnicity, and language data standardization for health care quality
improvement. Washington, D.C.: National Academies Press.
Hovenga, E. (n.d.). Health
information governance in a digital environment.
Englebardt, S., & Nelson, R.
(2002). Health care informatics: An interdisciplinary approach. St.
Louis: Mosby.
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