Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 The Electronic Medical Record Chapter 15

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Introduction Electronic Medical Records are the future of medical documentation. President Bush put forth an executive order that included the goal that every American’s medical records be in electronic form by 2014.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 This chapter will examine:  Difference between an electronic health record and an electronic medical record  Advantages and disadvantages of using electronic medical records systems  Capabilities of electronic medical records systems  Core capabilities of a national health information network  Role of the medical assistant in the midst of changing technology

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 Physicians Using Electronic Medical Records  Although only a small percentage of physicians use an electronic medical record system, this percentage is likely to grow each year.  Some physicians will never change to an electronic system due to personal preference and the cost involved.  Medical students are learning electronic systems and as they open their practices, they will likely incorporate electronic systems.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Executive Order  Issued by President George W. Bush in August 2006  Promotes interoperability of health records  Promotes overall quality and efficiency of records  Implementation date was January 1, 2007  Contains five requirements

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved Agencies are to implement interoperable systems as current systems are upgraded. 2. Providers and payors with whom agencies do business will also implement interoperable systems. 3. Prices paid to beneficiaries will be available both to beneficiaries and the public (if the agency chooses). 4. Agencies and providers will participate in development of information regarding the overall cost of healthcare services and treatments. 5. Agencies and providers will develop approaches that encourage high-quality and efficient health care. Requirements of an Executive Order

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7 Electronic Health Record  An electronic record of health-related information on a patient that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization involved with the patient’s care.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Electronic Medical Record  The aggregate electronic record of health-related information on a patient 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 patient’s health care. aggregate: looking at all units as a whole

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 Protected Health Information  Any information about health status, provision of health care, or payment for health care that can be linked to an individual patient.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Advantages of the EMR  Reduces medical errors  Keeps records organized  Helps to avoid duplicate testing  Less concern for illegible records  Requires individual names and passwords for security  Less storage space  Access information from various devices  Saves money  Promotes efficient patient care

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11 Disadvantages of the EMR  Reluctance of employees to embrace change  Patients’ concerns for confidentiality  High start-up costs  Extensive training necessary  Space for equipment needed  Interaction of office system with outside systems  Security issues

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12 Capabilities  Specialty software  Appointment scheduler  Appointment reminder and confirmation  Prescription writer  Medical billing system  Charge capture  Eligibility verification

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13 Capabilities (cont’d)  Referral management  Lab order integration  Patient portal

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14 The Patient and the EMR  Patients worry about the security of their health information.  Patients may file lawsuits for unauthorized access to their medical records.  Expect hesitation and reluctance from patients.  Be prepared to answer patient questions.  Know how the EMR is protected and the security measures that are in place so that patients can be reassured.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15 Additions and Corrections to the EMR  Never delete a previous entry.  Never change an entry after initials are attached.  Make a new entry to correct the error.  Note initials and date of change.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16 Nonverbal Communications and the EMR  Make certain that nonverbal communications send the right message to the patients.  Eye contact is essential.  Do not stare at the computer screen constantly.  Make the patient feel a part of the process.  Remember that the patient has the right to choose and make his or her own decisions regarding health care.  Maintain timely communication with the patient.  Make sure the patient understands instructions by watching body language signals.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17 Nationwide Health Information Network (NHIN) Developed to provide a secure, national, interoperable health information infrastructure that will connect providers, consumers, and others in supporting health care.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18 Goals of NHIN  Development of capabilities for standards-based, secure data exchange nationwide  Improvement of the coordination of care information among hospitals, laboratories, physician offices, pharmacies, and other providers  Ensure appropriate information is available at time and place of care  Ensure that consumers’ health information is secure and confidential

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19 Goals of NHIN  Giving consumers new capabilities for managing and controlling personal health records and providing access to health records  Reducing risks from medical errors and supporting the delivery of appropriate, evidence-based medical care  Lowering healthcare costs resulting from inefficiencies, medical errors, and incomplete patient information

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20 Core Capabilities of NHIN  Ability to find and retrieve healthcare information with and between organizations  Ability to deliver a summarized patient record to support patient care and to support the patient’s health  Ability to support consumer preferences regarding the exchange of his or her information, including the ability to choose not to participate in the NHIN

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21 Core Capabilities of NHIN  Support secure information exchange  Support of a common trust agreement that establishes the obligations and assurances to which all NHIN participants agree  Ability to match patients to their data without a national patient identifier  Support of harmonized standards among all entities and networks

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22 Backup Systems for the EMR  External hard drive  Full server backup  Online backup systems

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23 The Medical Assistant and the EMR  Daily use of the EMR should become second nature  Remain open to change and be willing to learn  Set a good example for other employees  Encourage other staff members during training  Be patient  Keep technical support phone numbers handy  Work as a team  Project a great attitude

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24 Summary of Scenario  Sometimes a medical assistant is not a good match for an office.  Perform to the utmost ability even if the job is unsatisfactory to get a good reference.  Do the job that you were hired to do.  Develop a strong work ethic.

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25 Closing Comments  Set the goal of quality, efficient health care.  Stay abreast of news and articles that relate to EMR systems.  Remember that the healthcare industry is one of constant growth and change.