Instructions: This assignment must be done in APA format. A minimum word countfor the overall assignment is 1600 words (not including reference portion). A
minimum requirement of 4-6 references (with in-text citations) is required.
Although this assignment is APA format, it must keep the answer and question
format. See details below.
Format for Assignment:
Question: XYZ
Answer: XYZ
Reference: XYZ
Instructor Notes: In professional writing avoid using first person “I” and third
person “we”, as they detract from the quality and turn professional researched
statements into opinions. Instead of “I” use, for example, use “the writer, the
author or the researcher”.
Instructors General Note:
Please answer these as three, numbered, separate questions. In each identify
specific case study examples of application.
Questions
1. What is the advantage of codified data over document imaged data?
2. Name at least three forces driving the change to the EHR.
3. Name at least two benefits of having patients entering their own symptoms
and history into the computer.
Reference Book: Gartee, R. (2011). Health information technology and
management. Upper Saddle River, NJ: Pearson.
Part Two
Instructions: Write an 150 word response to each post. A minimum of one (1)
reference is to be used (with in-text citatation). Each reference has to be
different. Be sure to wrote as of your talking to the person. Please be detailed as
possible.
1. The electronic health record (EHR) has completely transformed the process
in which patient specific data is collected, stored and retrieved. It creates an
avenue for providers and healthcare professionals to electronically access
past, present and future health related information on patients in order to
facilitate optimal communication and patient care delivery systems. With the
overwhelming majority of healthcare organizations having transitioned from
paper based health records to EHR, it has created the ability for users to
analyze, interpret and carry out timely processes for patient care services
regardless of the physical location of the individual. This platform embraces
the all encompassing patient centered approach while focusing on delivering
quality outcomes (Gartee, 2011).
Adverse drug events continue to result in drug toxicity, hospitalizations,
significant changes in functional status and drug-related mortality cases
across the industry (Cahir, C., Wallace, E., Cummins, A., Teljeur, C., Byrne, C.,
Bennett, K., & Fahey, T., 2019). Medical errors and other adverse events
occur far too often within the healthcare industry considering the level of
technology, education and safety measures that are regulated. One of the
driving forces for transitioning and fully adopting EHR would be the
availability of information that it would create for providers and other health
care professionals. Paper based records with multiple providers creates
increased opportunity that adverse events could potentially occur. Another
area supporting change is the advancing market of technology as healthcare
embraces this advancement through increasing efficiency. As diagnostic
testing, laboratory testing, point of service data entry and other electronic
information sources are collected, it is able to seamlessly be included into
the medical record. So much of the information that is reported to state,
federal and accrediting agencies is operating on an electronic platform, thus
having an EHR increases the collaborative telecommunications. Finally the
increased need for consumer EHR has created a demand for this service.
Patients embrace the ability to appropriately access their specific
information regarding their healthcare in order to discuss with providers.
Specialty providers also greatly benefit from the ability to electronically
share patient specific information while maintaining HIPAA Privacy
Rules (Gartee, 2011).
The Legislation enacted through the 106th Congress allowed the legal
recognition of electronic signatures to be used within EHR through secured
cryptographic techniques in order to provide integrity and non-repudiation
to the process (Nunno, R. M., & Bertot, J. C., 2000). The matter of creating
an electronic signature within EHR comes down to ensuring authentication
and security. Electronic signatures must offer message integrity, nonrepudiation and offer authentication. The element of integrity ensures that
the document has not been altered or inappropriately modified in any way.
Non-repudiation ensures that authorized users could not in any way deny
having electronically signed the document. Finally the user authentication
creates a reputable level of security in that the user was truly the individual
that signed the document. (Gartee, 2011).
Coded data that is accurately captured in a EHR ensures the specific diagnosis
or treatment is reflected according to the provider. Often, paper based
recording would create potential for error considering what a provider or
healthcare professional would enter into the record and then depending on
what the coder would interpret, inconsistencies were prevalent. Coding in
the EHR can also facilitate preventive care such as COPD or CHF to better
educate the patient of statistical data considering same gender and age
ranges. This service can also assist with data collecting for recommended
immunizations. By coding through the EHR, CDC (Center for Disease Control)
can offer beneficial recommendations considering the individuals
history (Gartee, 2011).
2. “An Electronic Health Record (EHR) is an electronic version of a patient’s
medical history that is maintained by the provider over time and may include
all of the key administrative clinical data relevant to that person’s care under
a particular data” (Electronic Health Records, 2012). While charting has
always had a place in healthcare organizations electronic forms have almost
completely replaced paper charts in the nation because of all of the positive
impacts and aspects it has had on the healthcare industry.
Three of the major forces that have driven this change to electronic health
records are health safety, healthcare costs, and the government response
(Gartee, 2011). With the use of electronic health records health safety has
greatly improved because they decrease miscommunications and allow for
healthcare organizations to easily retrieve data that can pinpoint where
safety can be improved upon. Electronic health records have also been
driven by healthcare costs because of all of their cost saving benefits such as
the money saved from error reduction and cutting healthcare costs have
been a major focus of the entire American healthcare system (Hammond,
Athanasiadou, Curado, Aphinyanaphongs, Abrams, Messito, & Elbel,
2019). Finally, the government response to electronic health records has
been immense starting with President Clinton implementing an order that
created government agencies to oversee these electronic medical records to
President Obama putting a large emphasis on utilizing electronic health
records in his implementation of the Affordable Care Act.
A part of the electronic health records is the electronic signature sing
physicians are no longer physically signing off on the patient’s charts. An
electronic signature consists of three main parts; message integrity,
nonrepudiation, and user authentication (Gartee, 2011). Message integrity
means that the physician can always confirm that the document has not
been alter after they have signed it, this typically is managed by the software
itself in which it does not allow edits to the portion of the chart that has been
signed
and
all
changes
are
written
as
an
additional
addendum. Nonrepudiation means that the signer, in this case typically a
physician, cannot deny that they were the one who signed this
document. This becomes increasingly tricky when physicians allow their
signatures to be used by proxy and have other people signing documentation
for them to sign out diagnostic reports and blood products. Finally, the user
authentication portion of the electronic signature is user
authentication. This means that the physician can confirm that the
document was signed by a real person and not just automatically signed by
a computer program. In the end electronic signatures do not only save time
for everyone involved but they are also protect the physician involved
(Electronic Signature Law, 2016).
Electronic health records also contain codified data which helps to create
more unified electronic health data across an entire healthcare organization
by identifying key words in the patient’s chart so that data can be more easily
be extracted (Yadav, Steinbach, Kumar, Simon, 2017). This codified data can
be used in several ways to help prevent disease in healthcare such as
automatically sending patients reminders when it is time to make
preventative or maintenance appointments and by assisting physicians in
decision support with pre-determined treatment protocols and standard
panels of testing for diagnostic purposes.
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