Terminology in Health Care and Public Health Settings

1
Terminology in Health Care and Public Health
Settings

• Unit 15
• Overview / Introduction to the EHR

2
Last Next Ten Years

• Improved Technology
• Government Support
• Receptivity of Healthcare Professionals
• Receptivity of Patients
• Use of Electronic Records
• Amount of Data

3
(No Transcript)
4
The Electronic Health Record

• Common acronyms for electronic records for
  patient data
• EHR electronic health record (across the
  lifespan)
• CBMR computer based medical record
• CPR computerized patient record
• EMR electronic medical record
• EPR electronic patient record
• PHR personal health record

5
Functions of the Health Record

• Document patient care
• Provide communication among healthcare team
  members
• Financial and legal record
• Research and continuous quality improvement
• Repository of the clinical thought processes
  recording ideas and impressions over the period
  of care
• Single point at which all clinical data are
  archived for long-term use

6
Attributes of the EHR

• Enormous capabilities of data storage in a small
  space
• Accessible from remote sites to multiple people
  at the same time
• Information retrieval can be almost instantaneous
• Provide clinical alerts, expert systems, and
  reminders

7
Attributes of the EHR

• Can link the clinician to protocols
• Create customized views
• Improve risk management
• Provide outcomes assessment
• More accurate capture of financial charges and
  billing efficiency
• Increases patient satisfaction

8
Data rich and information poor?
9
Rights of Information

• Right information must be accurate, free from
  error, and meaningful
• Right person communicated to the person who will
  respond to them
• Right time crucial to the health of an
  individual, give to the decision-maker within a
  few minutes or hours
• Right place must be accessible at the point of
  care
• Right amount decisions can be made faster when
  only the information desired is available

10
American Recovery and Reinvestment Act (ARRA)

• 19B for HITECH Health Information Technology
  for Economic and Clinical Health
• Center for Medicaid and Medicare Services (CMS)
• Incentive Payment, Meaningful Use
• Office of the National Coordinator for Health
  Information Technology (ONC)
• Certification Standards

11
Meaningful Use

• The effective use of information to support
  better decision-making and more effective care
  processes that improve health outcomes and reduce
  cost growth
• Data Capture and Sharing
• Advanced Clinical Processes
• Improved Outcomes

The Markel Foundation Connecting for Health,
Achieving the Health IT Objectives of the
American Recovery and Reinvestment Act April 2009
12
Data Capture and Sharing

• Improve Quality, Safety and Efficiency
• Engage Patients and Families
• Improve Care Coordination
• Improve Population and Public Health
• Ensure Privacy and Security Protections

13
Improve Quality

• Use CPOE
• Formulary Checks
• Problem List
• e-Prescribe
• Rx List
• Rx Allergy List
• Record Demographics
• Record physiological data
• Growth charts for children between 2 and 20

• Record Smoking (gt 13 Yrs)
• Structured Lab Results
• List Patient by Condition
• Report Quality Measures
• Patient Reminders (50 Yrs or gt)
• Clinical Decision Support ("Relevant to Clin
  Quality Measures)
• Check Eligibility
• Submit Electronic Claims

14
Engage Patients and Families

• Patient e-Access on Request (Including Discharge
  Summary/ Instructions from hospital)
• Patient e-Access to Record (Patient Portal)
• Clinical Summaries each Visit (Portal, email, CD,
  USB, Paper)

15
Improve Care Coordination

• Exchange Health Info with other Provider
• Medication Reconciliation
• Summary Care Record for each Transition/Referral
  Transfers w/Summary

16
Improve Population and Public Health

• e-Submit to Immunization Registries (Hospital
  also submits to Department of Public Health)
• Syndromic Surveillance to Department of Public
  Health

17
Final Revisions to the ARRA Meaningful Use Rule

• Final revisions to the rule July 13, 2010
• http//www.ofr.gov/OFRUpload/OFRData/2010-17210_PI
  .pdf

18
Summary of Objectives
The Meaningful Use Regulation for Electronic
Health Records. NEJM, July 13th,
2010 http//healthcarereform.nejm.org/?p3732