Y khoa - Dược - Chapter 12: Electronic health records

12Electronic Health RecordsLearning Outcomes (cont.)12.1 List four medical mistakes that will be greatly decreased through the use of EHR.12.2 Differentiate among electronic medical records, electronic health records, and personal health records12.3 Contrast the advantages and disadvantages  of electronic health recordsLearning Outcomes (cont.)12.4 Illustrate the steps in creating a new patient record and correcting an existing record using EHR software.12.5 Describe some of the capabilities of EHR software programs.12.6 Explain how you might alleviate a patient’s security fears surrounding the use of EHR.IntroductionElectronic health recordsEliminates duplication formsSimply review information A Brief History of Electronic Medical Records Paper records becoming inadequateMedical errors due to Lost or misfiled recordsMishandled patient messagesInaccurate and illegible documentsMislabeled or illegible lab or medication ordersApply Your KnowledgeANSWER: They are:Lost or misfiled recordsMishandled patient messagesInaccurate and illegible documentsMislabeled or illegible lab or medication orderWhat are the four errors that stem from communication problems?Electronic RecordsElectronic medical record (EMR)Electronic health record (EHR)Continuity of care Reduction in errorsDecreased costsPersonal health record (PHR)Apply Your KnowledgeMatch the following: PHI that is collected an maintained by the patient conforms to national interoperability standards not a legal record used by a single healthcare organization covered by HIPAAANSWER: EHR PHREMREHRAll threeEMRPHRPHRAdvantages and Disadvantages of EHRGovernment mandate stepsUse all major functions of EHRUse EHR to send and receive clinical informationAdvantages and Disadvantages of EHR (cont.)Clinical decisions support (in development)High priority conditionsEnrolling patients in PHRAccessing comprehensive dataImproving population healthE prescribing IncentivesDisadvantages of EHR ProgramsDisadvantagesCostlyStaff training requirementIT staff may be neededPossible damage to system and software and or required upgradesAdvantages of EHR ProgramsFewer lost medical records Eliminated transcription costs Increased readability/legibility Ease of chart access for multiple usersChart availability outside of office hours Advantages of EHR Programs (cont.)Increased access to patient education materials Decreased duplication of test ordersMore efficient transfer of recordsMore efficient billing processes Greatly decreased storage needsAdvantages of EHR Programs (cont.)Accessed from other locationsPhysician’s homeSatellite officesUsed in teleconferencesApply Your KnowledgeWhat is the main reason medical practices are not implementing EHRs?ANSWER: CostWorking With an Electronic Health RecordBasic rules unchangedCreating a New Patient Record Correcting an EHRWorking With an EHR (cont.)Be familiar with the hardware and softwareKeep password secureCheck entries carefully before savingApply Your KnowledgeWhich statements are true and which are false?____ All EHR programs will be  the same. ___ The basic rules for working with an EHR are the same  as for a paper record____ Once you make a mistake in an EHR, there is nothing  you can do to correct it. ANSWER:FTFAlthough programs must communicate with each other, they may not be the same.You can make an addendum with the correct information.Right!Other Functions of EHR ProgramsTickler filesSpecialty specific Customized Templates Other Functions of EHR Programs (cont.)Electronic schedulersAdvantages DisadvantageOther Functions of EHR Programs (cont.)Eligibility verification and referral managementBilling and codingOther Functions of EHR Programs (cont.)Report generatorsElectronic prescriptionsOther Functions of EHR Programs (cont.)Ancillary order integrationPatient accessApply Your KnowledgeMatch the following:ANSWER:Impressive!Tickler fileElectronic schedulerEligibility verificationBilling and codingReport generatorPrescription writerAncillary order integrationPatient access flags allergies checks insurance coverage sends an alert for follow-up care may send a reminder to the patient allow for electronic claims to  insurance companies office statistics make an appointment or pay a bill submits orders to the lab12345678Security and Confidentiality and EHRAccess codeLimits accessDate and time stamp Release of information policyBackupReassuring Others about EHR Security and ConfidentialityKnow the confidentiality and security featuresNo negativityPamphlet explaining EHRShow the patient his/her recordExplain access to patientApply Your KnowledgeANSWER: Access codes can be set to limit a person’s access to a medical record based on his/her job description. They also enable a medical practice to track who has accessed a medical record as well as when they accessed it.What does the use of access codes enable medical practice do?Right!In Summary12.1 Medical mistakes that will be greatly decreased or eliminated with EHR include: lost or misfiled paper recordsmishandled or “forgotten” patient messagesinaccurate or unreadable information in a paper medical recordmislabeled or unreadable laboratory or prescription orders.In Summary (cont.)12.2 The electronic medical record is an electronic record of health-related information for an individual patient. An electronic health record is created, managed, and gathered in a manner that conforms to nationally recognized interoperability standards. A personal health record is an electronic version of the comprehensive medical history and record of a patient’s lifelong health that is collected and maintained by the individual patient.In Summary (cont.)12.3 Advantages of EHR include: (not inclusive)Fewer lost recordsNo transcription costs Readability/legibility Access for multiple usersChart availabilityDecreased duplication of testsDisadvantages include: CostNeed for trainingPossible need for F/T or P/T IT personnelNeed for computer hardware/software upgrades or changesIn Summary (cont.)12.4 The same rules apply with EHR as for paper- based medical records when initiating or documenting in a patient’s electronic health record. Follow the basic steps in Procedure 12-1 for setting up a new patient EHR and 12-2 for correcting or making an addition in an existing patient’s electronic health record.In Summary (cont.)12.5 Aside from housing patient electronic health records, many EHR programs also can perform the following functions: tickler files, specialty-specific software, electronic scheduler, eligibility verification and referral management, billing and coding capabilities, report generation, electronic prescriptions and ancillary order integration, and a patient access portal.In Summary (cont.)12.6 Be knowledgeable of the office EHR program and never display a negative attitude about it. Assist in preparing written information for the patients regarding the EHR program. Show the patient his EHR, and explain how the information is entered, maintained, and kept secure. Understand and be able to explain the backup process for the EHR program. Understand the office access policy as it pertains to HIPAA and explain it to the patients.The over-all point is that new technology will not necessarily replace old technology, but it will date it. By definition. Eventually, it will replace it. ~ Steve Jobs End of Chapter 12