Electronic Health Records - PowerPoint PPT Presentation

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Electronic Health Records

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Title: Electronic Health Records


1
12
  • Electronic Health Records

2
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

3
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.

4
Introduction
  • Electronic health records
  • Eliminates duplication forms
  • Simply review information

5
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

6
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!
7
Electronic Records
  • Electronic medical record (EMR)
  • Electronic health record (EHR)
  • Continuity of care
  • Reduction in errors
  • Decreased costs
  • Personal health record (PHR)

8
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!
9
Advantages and Disadvantages of EHR
  • Government mandate steps
  • Use all major functions of EHR
  • Use EHR to send and receive clinical information

10
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

11
Disadvantages of EHR Programs
  • Disadvantages
  • Costly
  • Staff training requirement
  • IT staff may be needed
  • Possible damage to system and software and or
    required upgrades

12
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

13
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

14
Advantages of EHR Programs (cont.)
  • Accessed from other locations
  • Physicians home
  • Satellite offices
  • Used in teleconferences

15
Apply Your Knowledge
What is the main reason medical practices are not
implementing EHRs?
ANSWER Cost
Correct!
16
Working With an Electronic Health Record
  • Basic rules unchanged
  • Creating a New Patient Record
  • Correcting an EHR

17
Working With an EHR (cont.)
  • Be familiar with the hardware and software
  • Keep password secure
  • Check entries carefully before saving

18
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.
19
Other Functions of EHR Programs
  • Tickler files
  • Specialty specific
  • Customized
  • Templates

20
Other Functions of EHR Programs (cont.)
  • Electronic schedulers
  • Advantages
  • Disadvantage

21
Other Functions of EHR Programs (cont.)
  • Eligibility verification and referral management
  • Billing and coding

22
Other Functions of EHR Programs (cont.)
  • Report generators
  • Electronic prescriptions

23
Other Functions of EHR Programs (cont.)
  • Ancillary order integration
  • Patient access

24
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!
25
Security and Confidentiality and EHR
  • Access code
  • Limits access
  • Date and time stamp
  • Release of information policy
  • Backup

26
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

27
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!
28
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.

29
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.

30
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

31
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.

32
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.

33
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.

34
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
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