Western Governors University
NUT1 Task 1
What is EMR?
Electronic Medical Records
“a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.”(Santiago, n.d., para. 1)
Benefits of EMR
* Paper records can be reduced or completely eliminated.
* Less time consuming.
* Enhances efficiency.
* Reduces errors in documentation, as the process of entering information is streamlined. * Improves and speeds up work flow.
* Makes sharing of information across hospitals and healthcare providers possible. * Healthcare professionals have access to all pertinent health related information. * Facilitates easy decision-making.
* Enables delivery of evidence-based, quality care.
* Patient safety and confidentiality are improved.
A1. Benefits to Nursing Care
How will EMR benefit nursing Care?
* Immediate access to pertinent medical information.
* Standardized care planning.
* Immediate access to protocols and assessment guidelines. * Reduces “double charting” by auto-population of vital signs, lab results etc. to the patients flow sheet. * Reduces stress and saves time related to deciphering orders and handwriting legibility. * Reduce occurrence of medication errors with alerts for potential errors or medication interactions. * All the information of a patient is present at a centralized place, for easy access. * Improves the consistency and level of patient care, via evidence-based nursing. * Reminders of medications due or overdue.
Protected Heath Information (PHI)?
PHI includes any information, oral or recorded, that pertains to a persons health status, provisions of healthcare to an individual or payments for healthcare that can be directly linked to an individual ("Privacy/Data Protection Project," May 11, 2005)
PHI can be compromised in many ways
Example- an authorized user forgetting to log off the computer when finished with a task.
Example- large, planned data breaches to obtain, share or sell protected information by “hackers” How is PHI more vulnerable to breaches in confidentiality?
* Large amounts of information resulting in greater loss of private information. * Contains personal information used to engage in identity theft i.e. birthday, social security number, address and financial information etc. * Computer systems store large amounts of data that can be accessed remotely and shared remotely and under anonymity by “hackers”. What is HIPAA?
* HIPAA- Healthcare Information Portability and Accountability Act * Passed by the US Congress in 1996, HIPAA offers protection of personal healthcare information and medical records. It limits use and release of medical records and establishes privacy guidelines for healthcare providers. HIPAA also enforces strict penalties for any violation of privacy policies ("HIPAA Requirements MedicalRecords.com," n.d.). Security Measures- HIPAA
* Access to PHI is authorized to persons on a “need to know basis”. * All staff with access to PHI must be trained on the use and protection of PHI. * Authorized users must have a login id and password that must be changed at least every six months. * Staff must be instructed to keep login and passwords confidential and to logout of EMR after use. * Institutions store PHI in secure configurations or encryptions. * Routine audits by IT department to ensure continued safety of data and update systems and security measures as needed. * IT department performs routine back up of protected data . How can quality improvement data collected from the EMR system help to identify problems and errors? * By utilizing computerized databases and spreadsheets- eliminates errors in transcription and legibility ,...