Electronic Health Records

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12

• Electronic Health Records

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Learning 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 records
• 12.3 Contrast the advantages and disadvantages
  of electronic health records

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Learning 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 patients
  security fears surrounding the use of EHR.

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Introduction

• Electronic health records
• Eliminates duplication forms
• Simply review information

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A Brief History of Electronic Medical Records

• Paper records becoming inadequate
• Medical errors due to
• Lost or misfiled records
• Mishandled patient messages
• Inaccurate and illegible documents
• Mislabeled or illegible lab or medication orders

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Apply Your Knowledge
What are the four errors that stem from
communication problems?

• ANSWER They are
• Lost or misfiled records
• Mishandled patient messages
• Inaccurate and illegible documents
• Mislabeled or illegible lab or medication order

Excellent!
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Electronic Records

• Electronic medical record (EMR)
• Electronic health record (EHR)
• Continuity of care
• Reduction in errors
• Decreased costs
• Personal health record (PHR)

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Apply Your Knowledge

• Match 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 HIPAA

ANSWER EHR PHR EMR
PHR
EHR
PHR
EMR
All three
Nice Job!
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Advantages and Disadvantages of EHR

• Government mandate steps
• Use all major functions of EHR
• Use EHR to send and receive clinical information

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Advantages and Disadvantages of EHR (cont.)

• Clinical decisions support (in development)
• High priority conditions
• Enrolling patients in PHR
• Accessing comprehensive data
• Improving population health
• E prescribing
• Incentives

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Disadvantages of EHR Programs

• Disadvantages
• Costly
• Staff training requirement
• IT staff may be needed
• Possible damage to system and software and or
  required upgrades

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Advantages of EHR Programs

• Fewer lost medical records
• Eliminated transcription costs
• Increased readability/legibility
• Ease of chart access for multiple users
• Chart availability outside of office hours

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Advantages of EHR Programs (cont.)

• Increased access to patient education materials
• Decreased duplication of test orders
• More efficient transfer of records
• More efficient billing processes
• Greatly decreased storage needs

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Advantages of EHR Programs (cont.)

• Accessed from other locations
• Physicians home
• Satellite offices
• Used in teleconferences

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Apply Your Knowledge
What is the main reason medical practices are not
implementing EHRs?
ANSWER Cost
Correct!
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Working With an Electronic Health Record

• Basic rules unchanged
• Creating a New Patient Record
• Correcting an EHR

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Working With an EHR (cont.)

• Be familiar with the hardware and software
• Keep password secure
• Check entries carefully before saving

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Apply Your Knowledge
Right!
Which 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
Although programs must communicate with each
other, they may not be the same.
F
T
F
You can make an addendum with the correct
information.
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Other Functions of EHR Programs

• Tickler files
• Specialty specific
• Customized
• Templates

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Other Functions of EHR Programs (cont.)

• Electronic schedulers
• Advantages
• Disadvantage

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Other Functions of EHR Programs (cont.)

• Eligibility verification and referral management
• Billing and coding

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Other Functions of EHR Programs (cont.)

• Report generators
• Electronic prescriptions

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Other Functions of EHR Programs (cont.)

• Ancillary order integration
• Patient access

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Apply Your Knowledge
Match the following
ANSWER

1. Tickler file
2. Electronic scheduler
3. Eligibility verification
4. Billing and coding
5. Report generator
6. Prescription writer
7. Ancillary order integration
8. Patient 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 lab
6
3
1
2
4
5
8
7
Impressive!
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Security and Confidentiality and EHR

• Access code
• Limits access
• Date and time stamp
• Release of information policy
• Backup

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Reassuring Others about EHR Security and
Confidentiality

• Know the confidentiality and security features
• No negativity
• Pamphlet explaining EHR
• Show the patient his/her record
• Explain access to patient

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Apply Your Knowledge
What does the use of access codes enable medical
practice do?
ANSWER Access codes can be set to limit a
persons 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.
Right!
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In Summary

• 12.1 Medical mistakes that will be greatly
  decreased or eliminated with EHR include
• lost or misfiled paper records
• mishandled or forgotten patient messages
• inaccurate or unreadable information in a paper
  medical record
• mislabeled or unreadable laboratory or
  prescription orders.

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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 patients lifelong health that is
  collected and maintained by the individual
  patient.

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In Summary (cont.)

• 12.3 Advantages of EHR include (not inclusive)
• Fewer lost records
• No transcription costs
• Readability/legibility
• Access for multiple users
• Chart availability
• Decreased duplication of tests

• Disadvantages include
• Cost
• Need for training
• Possible need for F/T or P/T IT personnel
• Need for computer hardware/software upgrades or
  changes

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In Summary (cont.)

• 12.4 The same rules apply with EHR as for
  paper- based medical records when initiating or
  documenting in a patients 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
  patients electronic health record.

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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.

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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.

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End of Chapter 12
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