Medical Records Versus Administrative Records
Medical records versus administrative records are better tools to focus ONLY on the necessary and critical data pertinent to the subjects at hand. An advantage of medical records is that they provide access to clinical data that can showcase all of the data that the physician or health system determines as most important, they can be used for quality improvement and research purposes and they are not subject to the shortcomings or expenses of larger databases.
A major advantage of using medical records is their translatability. While administrative records may seem more concise on the outside, their coding can be complex to understand and in some cases can be too different from medical recording. It can be argued that administrative records are superior to medical records but not without addressing that physicians create medical records and in some ways, it is their responsibility to create documentation that can be translated into different types without changing the quality or content. An article in the Canadian Medical Association Journal (CMAJ) entitled Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study really highlights the aforementioned concept by saying “...physicians play a major role in influencing the quality of administrative data. There is a need for physicians to advocate for culture change in physicians' attitudes toward coders and chart documentation, in recognition of the importance of accurate chart information”.
Furthermore, another article from CMAJ suggests that one type of data collection can only be superior to the other if all parties using the data are using it accurately and responsibly; the author(s) essentially say “errors in diagnostic coding may occur along the diagnostic or administrative pathways” and further elaborate by discussing the importance of both the medical and administrative side of things being clear, consistent and universal.
Disadvantages of using data obtained from the medical record include there being the chance of missing data or records lacking specific patient information needed and there being difficulty or even too much variety in documentation as it can vary in nature and quality among healthcare personnel. E – C4 – Identify 4 ways in which e-health benefits patients. Name two barriers to using e-health. Explain your reasoning for all questions.
With the rise of technology, e-health has benefitted patients in so many different platforms. For one, in terms of the quality of care patients can receive, and secondly, with technology essentially being a universal language, e-health has greatly impacted many patients relationships with health and the way people seek out healthcare. In a clincal setting, E-health increases patient safety by reducing medical errors with the accuracy enabled by technology. Secondly, e-health provides more efficiency in care as it opens up more lines of communication, allowing the provider and patient to build a stronger relationship. Additionally, E-health can make transferring care easier for medical professionals. An article from Ovid Nursing highlights some benefits that the layperson might not think of off-hand but have supportive evidence to say that E-health benefits patients in many ways. For example the author mentions legibility and medication management and elaborates by saying “historically, illegible handwriting has been a prime source of medication errors… managing medications through an EHR improves patient outcomes over time. In fact, EHRs reduce adverse drug events by 52%. Some EHRs are designed to integrate with barcode scanning technology. If a nurse scans the wrong medication, an alert pops up alerting him or her to a problem.”
While legibility might sound like something that benefits providers most by being able to protect them from miscommunication, this in turns benefits patients ever so greatly and furthermore medication management can be a very stressful task for many providers, especially nurses on MedPass in facilities like nursing homes with several beds and by having alert systems and barcode scanning technology as aforementioned can also protect patients from so many adversities that arise with technology issues. The ways E-Health have benefits patients far surpass how it ensures better care for patients. E-health has opened lines of communication for patients to talk with people in online support groups with similar conditions, to provide self-education on many matters of health, be able to ask questions they may not feel comfortable asking their provider directly, and much more. Statistics from 2002 show that “80% find the information they look for online most or all of the time; 68% say that their last online search affected decisions about how to treat an illness, whether to visit a doctor, whether to ask new questions or whether to get a second opinion; 61% of e-patients say that getting health and medical information from the internet has improved the way they take care of their health by “a lot” or “some””. Most importantly, using online resources is extremely empowering for patients. Online support groups, for example, seem to really provide patients with education and feeling equal to their providers when discussing their condition or care.
The importance of the ability to gain information from online support groups is highlighted in the 2011 article from Patient Education and Counseling concluded that “60% of participants felt membership of an OSG had affected the relationship with their health professional and from qualitative responses the effects were mostly positive” and further concluded that the feeling of empowerment is directly rooted from the educational piece of online support groups, being that gaining information and being able to share experiences is what provides newfound confidence and understanding in patients’ about their conditions. Some barriers that can arise with E-health can be accepting information from people who are not professionals and subjecting yourself to have your information exploited.
