Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b – Definitions and Concepts in the EHR This material Comp3_Unit15 was developed by The University of Alabama Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000023

Definitions and Concepts in the EHR Learning Objectives Describe differences between EHR, EMR, and PHR Define the functional requirements of an EHR Identify the purposes of EHR components Describe methods to ensure data security and confidentiality 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

The Electronic Health Record Common acronyms for electronic records for patient data EHRelectronic health record (across the lifespan) CBMRcomputer-based medical record CPRcomputer-based patient record EPRelectronic patient record EMRelectronic medical record PHRpersonal health record 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Electronic Medical Records Electronic records –Become repositories of patient data –Reside with individual provider –Provide legal record of encounters Ambulatory Users –Physicians –Dentists –Pharmacists –Public Health Clinics –Opticians Acute Care Users –Hospitals –Emergency Care Centers –Surgical Centers Source:(Garets & Davis, 2006) 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Components of an Electronic Medical Record Clinical Systems Pharmacy Systems Laboratory Systems Admission/Discharge/Transfer Systems (ADT) Billing Systems 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Clinical Systems Clinical Documentation Clinical Decision Support (CDS) Computerized Provider Order Entry (CPOE) Bar-Code Medication Administration (BCMA) Electronic Medication Administration Record (eMAR) 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Personal Health Records “The Personal Health Record (PHR) is an Internet-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it.” Source:(Markle, 2003) 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Functions of Personal Health Records Information Sharing Information Exchange Information Self- management Source(CITL, 2008) 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Personal Health Record Models Payor tethered Provider tethered Third-Party tethered 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b Moving Toward the EHR

Attributes of the EHR Data Storage –Enormous capabilities –Small space Accessibility via secure servers –From remote sites –Multiple, authorized users at same time Information retrieval –Almost instantaneous 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Attributes of the EHR Links the clinician to protocols Offers customized views Improves risk management Provides outcomes assessment Results in more accurate capture of financial charges and billing efficiency Increases patient satisfaction 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Key EHR-Related Terms Computerized Provider Order Entry (CPOE) 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Key EHR-Related Terms Computerized Provider Order Entry (CPOE) Decision-Support Systems (DSS) –Clinical Decision Support System (CDS) 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Key EHR-Related Terms Computerized Provider Order Entry (CPOE) Decision-Support Systems (DSS) –Clinical Decision Support System (CDS) E-prescribing (eRx) –Use of computer devices to review drug and formularies –Electronic transmission of prescriptions to pharmacies –Integration with clinical decision support Source:(Office of the National Coordinator, 2012) 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Key EHR-Related Terms Computerized Provider Order Entry (CPOE) Decision-Support Systems (DSS) –Clinical Decision Support System (CDS) E-prescribing (eRx) Health Information Exchange (HIE) –Regional Health Information Organization (RHIO) –Nationwide Health Information Network (NwHIN) 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Data Security and Confidentiality 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Confidentiality and Security Confidentiality –Data/information is not available or disclosed to any unauthorized person or process –Includes paper and electronic records Sources:(Office for Civil Rights, 2006) 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Confidentiality and Security Confidentiality –Data/information is not available or disclosed to any unauthorized person or process –Includes paper and electronic records Security –Protects information from unauthorized access or destruction –Refers to all administrative, physical and technical safeguards that protect patient information Sources:(Office for Civil Rights, 2006) 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Legal Protections Health Insurance Portability and Accountability Act (HIPAA) –HIPAA Privacy Rule –HIPAA Security Rule Patient Safety Rule Enforced by Office for Civil Rights –Department of Health and Human Services Sources:(Office for Civil Rights, 2006 ) (Office for Civil Rights, 2008) 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Maintaining Security Uninterrupted power supply Back-ups Mirrored systems Off-site data storage Disaster recovery plans 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Security Measures to Maintain Confidentiality Authentication 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Security Measures to Maintain Confidentiality Authentication Audit Trails 23 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Security Measures to Maintain Confidentiality Authentication Audit Trails Firewalls Source:(Amatayakul, 2009, p 497) 24 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Security Measures to Maintain Confidentiality Authentication Audit Trails Firewalls Encryption 25 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Other Measures to Maintain Confidentiality Authentication Audit Trails Firewalls Encryption Confidentiality Statements 26 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Electronic Health Records Summary Identify the functions of the health record Describe the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 and the concept of “meaningful use” Describe differences between EHR, EMR, and PHR Define functional requirements of EHR Identify the purposes of EHR components Describe methods to ensure data security and confidentiality 27 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b

Electronic Health Records References – Lecture b References Amatayakul MK. Electronic health records: A practical guide for professionals and organizations. Chicago (IL): AHIMA; CITL. The value of personal health records. Center for Healthcare Technology Leadership, Available from: Garets D, Davis M. Electronic medical records vs. electronic health records: yes, there is a difference. Chicago (IL): HIMSS Analytics, 2006, p. 2. Available from: Office for Civil Rights. HIPAA Administrative Simplification; Regulation Text. US Department of Health and Human Services, Feb 16. Available from: Markle. Connecting for Health. A public-private collaborative. The personal health working group. Final report; 2003 Jul 1; New York: Markle Foundation. p. 3. Office for Civil Rights. The Patient Safety Rule. US Department of Health and Human Services Nov 21. Available from: Office of the National Coordinator for Health IT. Health IT terms. [Internet] Available from: ONC. Acronyms. Available from: Images Slides 7, 8, 17, 20, 21: Microsoft clip art; Used with permission from Microsoft. 28 Health IT Workforce Curriculum Version 3.0/Spring 2012 Terminology in Healthcare and Public Health Settings Electronic Health Records Lecture b