Monsour Roi M. Monzon, RN

 What is Electronic Health Record?  Electronic Medical Record (EMR) vs Electronic Health Record (EHR)  Comparison with Paper-based Records  Technical Features of an EHR  Benefits of Electronic Health Records  Safety and Privacy Concerns

 a systematic collection of electronic health information about an individual patient or population.  a record in digital format that is theoretically capable of being shared across different health care settings.

 Electronic medical records (EMRs): The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.  Electronic health records (EHRs): The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.

 Paper-based records require a significant amount of STORAGE SPACE compared to digital records.  When paper records are stored in different locations, collating them to a single location for review by a health care provider is TIME CONSUMING AND COMPLICATED, whereas the process can be simplified with electronic records.  When paper-based records are required in multiple locations, COPYING, FAXING, AND TRANSPORTING COSTS ARE SIGNIFICANT compared to duplication and transfer of digital records

 Identify and maintain a patient record  Manage patient demographics  Manage problem lists  Manage medication lists  Manage patient history  Manage clinical documents and notes  Capture external clinical documents  Present care plans, guidelines, and protocols  Manage guidelines, protocols and patient- specific care plans  Generate and record patient-specific instructions

 Health Information Exchange Technical and social framework that enables information to move electronically between organizations  ePrescribing  Sharing laboratory results with providers

 Improve quality and convenience of patient care.quality and convenience  Increase patient participation in their care.  Improve accuracy of diagnoses and health outcomes.diagnoses and health outcomes  Improve care coordinationcare coordination  Increase practice efficiencies and cost savings.practice efficiencies and cost savings

There are six ways in which electronic health record entities can provide superior security and privacy solutions once the EHR is implemented.

 Update policies and procedures  Guide employees through the stringent privacy and security training process  Run background checks on all employees

 Create physically inaccessible systems to unauthorized individuals  Have exigencies in place for data recovery or restoration  Provide identification and verification requirements to all system users  Access the list of authorized users  Supply passwords and personal identification numbers (PINs)  Provide automatic software shutdown routines

 Set privacy filters at each workstation  Distinguish the different capabilities of different workstations

 Identify any weakness in the system  Detect any security breach or attempt at a breach  Regularly audit all authorized users  Issue specified punishments to employees not following compliance guidelines

 Construct a security plan for data disposal  Remove data from reusable hardware  Track all reprocessed hardware  Back up all data from all hardware

 Disguise all data inside medical files through cryptography

Sources: 1. Foldy, Seth. (2011). Electronic Health Records: What’s in it for Everyone. Retrieved on April 15, 2014 from rounds/archives/2011/july2011.htm. rounds/archives/2011/july2011.htm 2. Hsiao, Chun-Ju and Hing, Esther. (2014). Use and Characteristics of Electronic Health Records. Retrieved on April 15, 2014 from Neal, Houston. (2008). EHR vs EMR – What’s the Difference?. Retrieved on April 15, 2014 from practice.softwareadvice.com/ehr-vs-emr-whats-the- difference/. practice.softwareadvice.com/ehr-vs-emr-whats-the- difference/