cpayne28

Laurin, you make a great point! It is becoming so much more important to have a standardization of terminology and language used in entering patient information. There is so much room for error when there is not a nationwide understanding of the expectations regarding documentation in the EHR. This is a huge patient safety issue. If the proper terminology is not used, it will lead to misinterpretation of patient information which is vital to provide quality care and ensure a quality outcome. This is so important for health care providers to understand when using EHR. The EHR is such a benefit to patient care in so many ways, but if used incorrectly it will have a huge negative impact on the outcome. UTGE2-CP

Kyle makes a great point! In order for there to be effective interoperability, following the standards of care is vital. The standards of care allow effective communication between health care providers, as well as accurate interpretation of the data entered into the EHR. The Hospital Readmissions Reduction Program is so important. Hospitals will receive a 2% revenue penalty from Medicare this year, and increases to a 3% revenue penalty in 2015 if a patient is readmitted to a hospital for the same diagnoses (Le, 2013). This, in addition to patient safety, is crucial for health care providers to understand when entering patient information. Accurate documentation is extremely important, and is quickly becoming one of the most critical components of the EHR. Le, P. (2013, October 01). Strategic interoperability: Unleashing the full potential of ehrs. Retrieved from Strategic interoperability.: EBSCOhost UTGE2:CP

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Interoperability is only successful if standards of use are followed. The standards provide detailed information and guidelines in order to ensure proper entry, structure, and interpretation of health information, in order to provide quality patient care in a timely manner."Appropriate, timely sharing of vital patient information can better inform decision making at the point of care and all providers to avoid readmissions, avoid medication errors, improve diagnoses, and decrease duplicate testing"(Health Information Exchange, n.d.). Without standards in place, many individuals would likely use different terms or abbreviations, that may be interpreted by another health care provider as something completely different. This is particularly important regarding medication administration. The issue of misinterpreting a medication order due to the inability to read a provider's handwriting, or misunderstanding an abbreviation, is one of the major benefits of EHR. If there is not a unified understanding nationwide of the correct meaning of specific information, it will not be interpreted correctly and will hinder patient care. In addition to playing a major role in communication between providers, standards also facilitate an understanding of the specific locations certain information should be documented. This is key in being able to effectively use Electronic Health Records. The purpose of implementing the EHR is being able to access a full, accurate source of all health information in a timely manner in order to provide quality care. If health care providers are not able to locate pertinent records in a timely manner due to a lack of organized information, it is simply pointless. United States, National Coordinator for Health Information Technology. (n.d.). Health Information Exchange. Retrieved April 19, 2014, from http://www.healthit.gov/HIE Christen (Tori) Payne