Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

2014 ◽  
Vol 10 (9) ◽  
pp. 660-665 ◽  
Author(s):  
Patricia C. McMullen ◽  
William O. Howie ◽  
Nayna Philipsen ◽  
Virletta C. Bryant ◽  
Patricia D. Setlow ◽  
...  
2016 ◽  
Vol 78 (6) ◽  
Author(s):  
Vairamuthu S. ◽  
Margret Anouncia

Developing applications using Multi Modal Human Computer Interaction (MMHCI) remains a great challenge due to the advancement of technologies. Enhanced interaction applications and tools employed in medical records will help to improve the quality of patients’ healthcare and it opens a variety of research challenges. Replacing a difficult system to store complex data related to medical history of patients through Electronic Medical Records (EMR)/Electronic Health Records (EHR) would offer several advantages that include confidentiality and patient details reliability along with the mechanisms for quick and flexible retrieval of data/information. The task of designing MMHCI applications for real time environment for EMR/EHR is thus complex. As the inputs to medical systems are heterogeneous, the associated issues grow up with the need for new system since the existing frameworks have many gaps and drawbacks. This paper attempts to discuss the possible guidelines, standards, tools and techniques involved in integrating MMHCI with EMR/EHR.


Author(s):  
Carlos Andrés Moque Millán ◽  
Alexandra Pomares Quimbaya ◽  
Rafael A. Gonzalez

One of the most important inputs for medical research is the information registered in electronic medical records. This information typically contains sensitive data that must be preserved in order to be used for research or educational purposes, and protected depending on the regulations of each country and institution. In order to assure confidentiality of data, different techniques can be used to remove basic identifiers (e.g. names, IDs); however, these techniques can be easily bypassed by attackers who know the information that can act as pseudo-identifiers of patients (e.g. birthdates, gender). Although these pseudo-identifiers can also be removed, the information they contain is valuable for medical research. To face this problem, different methods that allow minimizing the risk of sharing confidential information have been proposed. The interactive use of anonymization algorithms for electronic medical records is the main contribution of this chapter, dubbed AnonymousData.co: a proposal for anonymization of electronic health records.


2012 ◽  
Vol 147 (2_suppl) ◽  
pp. P11-P11
Author(s):  
K. J. Lee ◽  
Edward B. Ermini ◽  
Subinoy Das ◽  
David R. Nielsen ◽  
Gordon H. Sun

Author(s):  
Juan C. Lavariega ◽  
Roberto Garza ◽  
Lorena G Gómez ◽  
Victor J. Lara-Diaz ◽  
Manuel J. Silva-Cavazos

The use of paper health records and handwritten prescriptions are prone to preset errors of misunderstanding instructions or interpretations that derive in affecting patients' health. Electronic Health Records (EHR) systems are useful tools that among other functions can assists physicians' tasks such as finding recommended medicines, their contraindications, and dosage for a given diagnosis, filling prescriptions and support data sharing with other systems. This paper presents EEMI, a Children EHR focused on assisting pediatricians in their daily office practice. EEMI functionality keeps the relationships among diagnosis, treatment, and medications. EEMI also calculates dosages and automatically creates prescriptions which can be personalized by the physician. The system also validates patient allergies. This paper also presents the current use of EHRs in Mexico, the Mexican Norm (NOM-024-SSA3-2010), standards for the development of electronic medical records and its relationships with other standards for data exchange and data representation in the health area.


2012 ◽  
Vol 19 (2) ◽  
pp. 117-126 ◽  
Author(s):  
M Diane Lougheed ◽  
Janice Minard ◽  
Shari Dworkin ◽  
Mary-Ann Juurlink ◽  
Walley J Temple ◽  
...  

In a novel knowledge translation initiative, the Government of Ontario’s Asthma Plan of Action funded the development of an Asthma Care Map to enable adherence with the Canadian Asthma Consensus Guidelines developed under the auspices of the Canadian Thoracic Society (CTS). Following its successful evaluation within the Primary Care Asthma Pilot Project, respiratory clinicians from the Asthma Research Unit, Queen’s University (Kingston, Ontario) are leading an initiative to incorporate standardized Asthma Care Map data elements into electronic health records in primary care in Ontario. Acknowledging that the issue of data standards affects all respiratory conditions, and all provinces and territories, the Government of Ontario approached the CTS Respiratory Guidelines Committee. At its meeting in September 2010, the CTS Respiratory Guidelines Committee agreed that developing and standardizing respiratory data elements for electronic health records are strategically important. In follow-up to that commitment, representatives from the CTS, the Lung Association, the Government of Ontario, the National Lung Health Framework and Canada Health Infoway came together to form a planning committee. The planning committee proposed a phased approach to inform stakeholders about the issue, and engage them in the development, implementation and evaluation of a standardized dataset. An environmental scan was completed in July 2011, which identified data definitions and standards currently available for clinical variables that are likely to be included in electronic medical records in primary care for diagnosis, management and patient education related to asthma and COPD. The scan, sponsored by the Government of Ontario, includes compliance with clinical nomenclatures such as SNOMED-CT®and LOINC®. To help launch and create momentum for this initiative, a national forum was convened on October 2 and 3, 2011, in Toronto, Ontario. The forum was designed to bring together key stakeholders across the spectrum of respiratory care, including clinicians, researchers, health informaticists and administrators to explore and recommend a potential scope, approach and governance structure for this important project. The Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE) goal is to recommend respiratory data elements and standards for use in electronic medical records across Canada that meet the needs of providers, administrators, researchers and policy makers to facilitate evidence-based clinical care, monitoring, surveillance, benchmarking and policy development. The focus initially is expected to include asthma, chronic obstructive pulmonary disease and pulmonary function standards elements that are applicable to many respiratory conditions. The present article summarizes the process and findings of the forum deliberations.


Author(s):  
Muhammad Anshari

A successful healthcare organization exists when it provides good quality service. Powered by technological changes like big data, cloud computing, and Internet of Things, healthcare information is accessed and owned and the patient has become evolving within the healthcare environment. This affects the relationship between healthcare provider and customers, and between patients. Electronic Health Records (EHRs) and Electronic Medical Records (EMRs) are considered as a building block for electronic health development. Many literatures use both terms EHR and EMR interchangeably with no clear distinction in terms of scope and dimensions. The aim of the research is to examine the distinct role of EHR from EMR in order to promote patients’ empowerment.  While, patient empowerment in e-health will enhance patients’ satisfaction, improve their health literacy, and involve patient in the process of health decision making.


2019 ◽  
Vol 32 (01) ◽  
pp. 082-090
Author(s):  
Jacob Carlson ◽  
Jonathan Laryea

AbstractElectronic health records (EHRs) or electronic medical records (EMRs) contain a vast amount of clinical data that can be useful for multiple purposes including research. Disease registries are collections of data in predefined formats for population management, research, and other purposes. There are differences between EHRs and registries in the data structure, data standards, and protocols. Proprietary EHR systems use different coding systems and data standards, which are usually kept secret. For EHR data to flow seamlessly into registries, there is the need for interoperability between EHR systems and between EHRs and registries. The levels of interoperability required include functional, structural, and semantic interoperability. EHR data can be manually mapped to registry data, but that is a tedious, resource-intensive endeavor. The development of data standards that can be used as building blocks for both EHRs and registries will help overcome the problem of interoperability.


2020 ◽  
Vol 33 (6) ◽  
pp. 384 ◽  
Author(s):  
Joelizy Oliveira ◽  
Ana Cristina Cabral ◽  
Marta Lavrador ◽  
Filipa A. Costa ◽  
Filipe Félix Almeida ◽  
...  

Introduction: Obtaining the best possible medication history is the crucial step in medication reconciliation. Our aim was to evaluate the potential contributions of the main data sources available – patient/caregiver, hospital medical records, and shared electronic health records – to obtain an accurate ‘best possible medication history’.Material and Methods: An observational cross-sectional study was conducted. Adult patients taking at least one medicine were included. Patient interview was performed upon admission and this information was reconciled with hospital medical records and shared electronic health records, assessed retrospectively. Concordance between sources was assessed. In the shared electronic health records, information was collected for four time-periods: the preceding three, six, nine and 12-months. The proportion of omitted data between time-periods was analysed.Results: A total of 148 patients were admitted, with a mean age of 54.6 ± 16.3 years. A total of 1639 medicines were retrieved. Only 29% were collected simultaneously in the three sources of information, 40% were only obtained in shared electronic health records and only 5% were obtained exclusively from patients. The total number of medicines gathered in shared electronic health records considering the different time frames were 778 (three-months), 1397 (six-months), 1748 (nine-months), and 1933 (12-months).Discussion: The use of shared electronic health records provides data that were omitted in the other data sources available and retrieving the information at six months is the most efficient procedure to establish the basis of the best possible medication history.Conclusion: Shared electronic health records should be the preferred source of information to supplement the patient or caregiver interview in order to increase the accuracy of best possible medication history of the patient, particularly if collected within the prior six months.


Author(s):  
MOHAMED HOSSAM ATTIA ◽  
ABDELNASSER IBRAHIM

Objective: Electronic health records (EHRs) are considered a way to make the management of patient information easier, improve efficiency, and decrease costs related to medical information management. Compliance with requirements from accreditation bodies on quality of documentation ensures the complete and accurate patient information in the EHR. The purpose of this study is to measure the effect of quality accreditation on the quality of documentation in the EHR. Methods: A simple random sample of 18% of patient records was manually selected each month during the entire study period from the population of discharged patients. The auditing process included 18 months starting from January 2014 until June 2015. The data collection was performed by a quality management unit using a modified medical record completeness checklist adapted from Joint Commission International (JCI) criteria. Results: The results of the study show the improvement in compliance with complete medical records’ documentation after the JCI accreditation. However, after the accreditation, the compliance suffers a dramatic fall which could be referred to the post-accreditation slump. The compliance then improved again to reach higher levels of compliance. Using paired t-test, the mean of total compliance with complete and accurate medical records in October 2014 was less than in May 2015. Conclusion: This study highlighted the performance of one process before and after the first accreditation of the organization showing the real difference between the performance before and after the accreditation and explaining the drop that happened just after the accreditation.


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