The Electronic Health Record (EHR) is comprised of many components that work together to capture, create, share, maintain and store an accurate and complete patient health record. There are various systems, applications, standards and specifications that must be in place in order to meet the goal of true interoperability.
Read AHIMA's Policy and Position Statement: Appropriate Use of the Copy and Paste Functionality in Electronic Health Records
AHIMA has released the Policy and Position Statement on Copy and Paste to stimulate stakeholders discussions and action about digital documentation practices in the absence of formal guidelines and practice standards. The lack of such standards is resulting in real and potential concerns about patient care, patient safety, and the reliability of health care data and information. AHIMA has been working on this topic for many years as part of its ongoing efforts toward improving health information management and data collection in EHRs, and is incorporating reliance of appropriate standards in its work on Information Governance for healthcare.
The proverbial walls of the HIM department are vanishing as the healthcare landscape changes, but there are many doors opening that need the HIM professional’s skills and expertise.
While operations still demand continued focus on day-to-day activities like EHR implementation, coding, revenue cycle, privacy and security , and release of information (ROI) to name a few; health information exchange (HIE) and other emerging technologies and payment reform initiatives are rapidly changing how healthcare documentation will be created, managed and shared in the future.
EHRs are being implemented at a rapidly advancing rate which calls for sound information management principles with the goal of accurately and timely share information. In this digital age, consumers are worried about the privacy and security of their health information and many organizations, vendors and workgroups are collaborating to create new and innovative ways of handling health information. The goal is to ensure processes, systems and technologies are in line with capturing data to enable sharing and getting information at “where and when it’s needed”.