Chapter 1 Introduction to Electronic Health Records Copyright

What is a Medical Record? A physical collection of an individual’s healthcare information Used

Contents of the Electronic Health Record Each patient has their own record Documentation is

Health Information Medication lists Allergy lists Immunization records Laboratory reports Pathology reports Surgical reports

Administrative Information Patient information form Referral letters Consultation letters Insurance information Billing information Appointment

Legal Documents Records release Informed consent documents HIPAA forms Advance directives Living wills Insurance

Documenters of the Medical Record Individual who is responsible for inputting information into the

Ownership of the Medical Record Property of the individual who created it Physician office

The Electronic Health Record (EHR) Patient medical record in an electronic format Eight core

Eight Core Functions Health information & data management Results management Order management Decision support

Transitioning from Paper to Electronic Records Office of the National Coordinator of Health Information

EHR Versus EMR Interconnected aggregate of all the patient’s health records From multiple providers

Practice Partner Basic Functions Progress note Documentation templates Provider review of incoming data Image

Clinical Decision Support (CDS) Automated preventive care reminders Treatment plan templates Generates pt. data

Practice Management Software Administrative software used for: Patient demographics Ø Billing and insurance information

Practice Management Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 16

Practice Management (cont’d. ) Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

EHR Advantages Improved quality and continuity of care Management of chronic disease Disaster preparedness

EHR Disadvantages Lack of interoperability Cost Financial investment Time Employee resistance Regimentation Security gaps

Early and Late Adopters The following factors affect user satisfaction: Length of system response

Role of the Healthcare Professional Basic skills needed: Knowledge of medical terminology Ø Basic

Administrative Duties Receptionist duties Appointment scheduling Electronic chart creation Purging Entering patient data Creating

Clinical Duties Document treatment Coordinate patient care Document: Patient H&P Ø Vital signs Ø

Billing and Coding Duties Creation of billing statements Assignment of procedural and diagnostic codes

Professional Organizations Benefits: Offer certification exams Ø Continuing education unit (CEU) opportunities Ø Networking

Professional Organizations (cont’d. ) American Health Information Management Association (AHIMA) American Academy of Professional

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What is a Medical Record? A physical collection of an individual’s healthcare information Used throughout history to document: Patient healthcare Ø Signs and symptoms Ø Diseases Ø Trends of disease Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 2

Contents of the Electronic Health Record Each patient has their own record Documentation is a vital component of the EHR Contains: Health information Ø Administrative information Ø Legal documents Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 3

Health Information Medication lists Allergy lists Immunization records Laboratory reports Pathology reports Surgical reports Hospital records H&P Progress notes Radiology reports Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 4

Administrative Information Patient information form Referral letters Consultation letters Insurance information Billing information Appointment history Diagnostic and procedure codes Emergency contact information Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 5

Legal Documents Records release Informed consent documents HIPAA forms Advance directives Living wills Insurance authorization forms Healthcare power of attorney forms Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 6

Documenters of the Medical Record Individual who is responsible for inputting information into the medical record: documenter Receptionist Ø Medical assistant Ø Physician (or other treating professional) Ø Medical biller Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 7

Ownership of the Medical Record Property of the individual who created it Physician office owns the physical record Patient owns the medical information May obtain a copy by signing a records release Ø May be charged an administrative fee Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 8

Eight Core Functions Health information & data management Results management Order management Decision support Electronic communication & connectivity Patient support Administrative processes Reporting and population health Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 10

Transitioning from Paper to Electronic Records Office of the National Coordinator of Health Information Technology (ONCHIT) Computerized physician order entry (CPOE) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 11

EHR Versus EMR Interconnected aggregate of all the patient’s health records From multiple providers From multiple healthcare facilities Electronic patient record created & maintained Component of the EHR Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 12

Practice Partner Basic Functions Progress note Documentation templates Provider review of incoming data Image attachment Electronic signature insertion Prescription (CPOE) templates Fax & messaging Patient reminders Vital signs data Importation of data Automatic flagging Email Print Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 13

Clinical Decision Support (CDS) Automated preventive care reminders Treatment plan templates Generates pt. data reports Documentation templates Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 14

Practice Management Software Administrative software used for: Patient demographics Ø Billing and insurance information Ø Appointment scheduling Ø Advanced accounting practices Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 15

EHR Advantages Improved quality and continuity of care Management of chronic disease Disaster preparedness Job & patient satisfaction Increased efficiency Improved documentation Easier accessibility at point of care Better security Reduced expense Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 18

Early and Late Adopters The following factors affect user satisfaction: Length of system response time Ø Perception of workflow logic Ø Ability to complete tasks Ø Ease of mistake correction Ø Training time Ø Availability of support staff Ø System effect on quality of care Ø Ability to convert systems to specific provider needs Ø Level of computer skills Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 20

Role of the Healthcare Professional Basic skills needed: Knowledge of medical terminology Ø Basic typing and computer skills Ø Organizational skills Ø Interpersonal skills Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 21

Administrative Duties Receptionist duties Appointment scheduling Electronic chart creation Purging Entering patient data Creating patient letters Email communication Patient education Coordination of care Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 22

Clinical Duties Document treatment Coordinate patient care Document: Patient H&P Ø Vital signs Ø Progress notes (details of patient visit) Ø Laboratory requisitions Ø Prescriptions Ø Test results Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 23

Billing and Coding Duties Creation of billing statements Assignment of procedural and diagnostic codes Link codes for reimbursement Auditing Filing patient statements Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 24

Professional Organizations Benefits: Offer certification exams Ø Continuing education unit (CEU) opportunities Ø Networking Ø Newsletters and professional journals Ø Discounts on publications Ø Sponsor conferences, workshops, and web-based activities Ø Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 25

Professional Organizations (cont’d. ) American Health Information Management Association (AHIMA) American Academy of Professional Coders (AAPC) American Association of Medical Assistants (AAMA) American Medical Technologists (AMT) Copyright © 2011 by Saunders, an imprint of Elsevier Inc. 26