MO 250: MEDICAL RECORDS: ELECTRONIC HEALTH RECORD MANAGEMENT

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MO 250 MEDICAL RECORDS ELECTRONIC HEALTH RECORD
MANAGEMENT

• UNIT 5 SEMINAR

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INTRODUCTION

• According to your text, in an acute care setting,
  an electronic health record integrates electronic
  data from multiple clinical systems to provide a
  single access point for information about a
  patients health care. These systems commonly
  include data for ancillary services such as
  laboratory, radiology, and pharmacy systems,
  among others.

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Discussion

• 1. Discuss the functions of an EHR in an acute
  care hospital.

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Discussion

• Functions of EHR in an acute care hospital
• Financial information
• Laboratory information systems
• Pharmacy information systems
• Picture archiving and communication systems
• Radiology information systems
• Clinical information systems

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discussion

• 2. Discuss the benefits of a hospital EHR.

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Discussion

• Benefits of hospital EHR
• Immediate access to complete, up-to-date
  information about patients, including progress
  notes, results of laboratory tests and imaging
  studies, medication administration, and responses
  to treatment
• Decreased turnaround times for medication
  delivery and completion of diagnostic tests due
  to electronic delivery of orders and results.

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discussion

• Benefits of EHR (cont.)
• Increased efficiency by standardizing work
  processes and by integrating information from
  different departments.
• The main benefit of EHRs, however, is not their
  ability to provide fast access to current and
  complete patients records.
• The most significant contribution of EHRs is that
  they offer decision-support tools that help
  physicians make diagnosis and treatment decisions
  that provide patients with the safest, most
  effective care.

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discussion

• 3. How is clinical documentation used in an
  inpatient setting?

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discussion

• Use of clinical documentation in a inpatient
  setting
• Assist in patient care planning and continuity of
  care
• Provide evidence of the course of the patients
  care and treatment during the hospital stay
• Facilitate communication among members of the
  patient care team

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discussion

• Use of clinical documentation in a inpatient
  setting
• Serve as a legal record to protect the interests
  of the patient, the hospital , and the clinician
• Supply data for research purposes
• Supply data for utilization review and quality
  improvement analysis and reporting
• Providing information that enables coders to
  determine the appropriate diagnosis and procedure
  codes to substantiate patient billing.

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discussion

• 4. What are the advantages of CPOE (computerized
  physician order entry)?

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discussion

• Advantages of CPOE
• Provides alerts that warn against the possibility
  of drug interactions, allergies, overdoses, or
  other problems.
• Provides accurate, up-to-date information on new
  medications, procedures, and research
• Improves communication among team members
• Provides physicians with access to
  decision-support tools at the point-of-care

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discussion

• Advantages of CPOE
• Reduces the amount of time it takes to fill
  physician orders
• Eliminates the change of an order being misplaced
  or lost
• Eliminates errors resulting from illegible
  handwriting
• Enables orders to be entered from any location
  with computer access in the hospital or off-site

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discussion

• Advantages of CPOE
• Provides easier access to data for reporting and
  quality assessment purposes
• Reduces costs by improving efficiency,
  eliminating duplicate tests, and reducing the
  number of lawsuits due to medication errors.

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discussion

• 5. How does decision support tools improve the
  quality of patient care?

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discussion

• Q5A Decision support tools allow physicians to
  select medications, diagnostic tests and
  treatments which results in improved quality of
  care and patient outcomes.

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discussion

• 6. Discuss how the combination of the CPOE and
  the E-MAR can assist in reducing errors.

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discussion

• Q6A CPOE eliminates errors that can occur as a
  result of illegible handwriting by enabling
  physicians to enter patient orders using a
  computer. When a physician orders a medication
  using CPOE, the order is automatically entered in
  the electronic medical administration records.
  From that point on, the medication order and its
  administration are tracked by computer using
  barcode technology.

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discussion

• 7. What are the advantages of electronic results
  reporting over traditional paper-based reporting
  systems?

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discussion

• Q7A Advantages of electronic results reporting
• Faster turnaround time there is minimal delay
  between the time the test is finished and the
  availability of results. Results can be accessed
  from any computer with network access.
• Faster diagnosis and treatment once clinicians
  are alerted that results are available, they can
  review the results and consider how that
  information affects the possible diagnosis.

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discussion

• Q7A Advantages of electronic results reporting
• Efficient consultations more than one physician
  can view the images at the sample time, even if
  the physicians are not in the same location.
• Faster medication administration the laboratory
  test results for hospitalized patients are
  available more quickly, which makes it possible
  for patients to receive their medication sooner.

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discussion

• Q7A Advantages of electronic results reporting
• Fewer duplicate tests since there is a
  computerized record of every test ordered during
  a patients hospital stay, providers will see
  that a test has already been performed before
  unknowingly ordering a duplicate test.
• Enhanced analysis results from lab tests such as
  glucose levels or cholesterol levels can be
  viewed in graphical format, making it easier to
  spot trends in results over time.

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discussion

• Q7A Advantages of electronic results reporting
• Easier retrieval since images and results are
  stored on a computer, they are easy to locate and
  review when necessary.

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reference

• Sanderson, S.M. (2009). Electronic health records
  for allied health careers New York, NY
  McGraw-Hill.