1. UNIT 5 SEMINAR

2.  According to your text, in an acute care setting, an electronic health record integrates electronic data from multiple clinical systems to provide a single access point for information about a patient’s health care. These systems commonly include data for ancillary services such as laboratory, radiology, and pharmacy systems, among others.

3.  1. Discuss the functions of an EHR in an acute care hospital.

4.  Functions of EHR in an acute care hospital:  Financial information  Laboratory information systems  Pharmacy information systems  Picture archiving and communication systems  Radiology information systems  Clinical information systems

5.  2. Discuss the benefits of a hospital EHR.

6.  Benefits of hospital EHR:  Immediate access to complete, up-to-date information about patients, including progress notes, results of laboratory tests and imaging studies, medication administration, and responses to treatment  Decreased turnaround times for medication delivery and completion of diagnostic tests due to electronic delivery of orders and results.

7.  Benefits of EHR (cont.):  Increased efficiency by standardizing work processes and by integrating information from different departments.  The main benefit of EHRs, however, is not their ability to provide fast access to current and complete patients records.  The most significant contribution of EHRs is that they offer decision-support tools that help physicians make diagnosis and treatment decisions that provide patients with the safest, most effective care.

8.  3. How is clinical documentation used in an inpatient setting?

9.  Use of clinical documentation in a inpatient setting:  Assist in patient care planning and continuity of care  Provide evidence of the course of the patient’s care and treatment during the hospital stay  Facilitate communication among members of the patient care team

10.  Use of clinical documentation in a inpatient setting:  Serve as a legal record to protect the interests of the patient, the hospital, and the clinician  Supply data for research purposes  Supply data for utilization review and quality improvement analysis and reporting  Providing information that enables coders to determine the appropriate diagnosis and procedure codes to substantiate patient billing.

11.  4. What are the advantages of CPOE (computerized physician order entry)?

12.  Advantages of CPOE:  Provides alerts that warn against the possibility of drug interactions, allergies, overdoses, or other problems.  Provides accurate, up-to-date information on new medications, procedures, and research  Improves communication among team members  Provides physicians with access to decision- support tools at the point-of-care

13.  Advantages of CPOE:  Reduces the amount of time it takes to fill physician orders  Eliminates the change of an order being misplaced or lost  Eliminates errors resulting from illegible handwriting  Enables orders to be entered from any location with computer access in the hospital or off-site

14.  Advantages of CPOE:  Provides easier access to data for reporting and quality assessment purposes  Reduces costs by improving efficiency, eliminating duplicate tests, and reducing the number of lawsuits due to medication errors.

15.  5. How does decision support tools improve the quality of patient care?

16.  Q5A: Decision support tools allow physicians to select medications, diagnostic tests and treatments which results in improved quality of care and patient outcomes.

17.  6. Discuss how the combination of the CPOE and the E-MAR can assist in reducing errors.

18.  Q6A: CPOE eliminates errors that can occur as a result of illegible handwriting by enabling physicians to enter patient orders using a computer. When a physician orders a medication using CPOE, the order is automatically entered in the electronic medical administration records. From that point on, the medication order and its administration are tracked by computer using barcode technology.

19.  7. What are the advantages of electronic results reporting over traditional paper- based reporting systems?

20.  Q7A: Advantages of electronic results reporting:  Faster turnaround time: there is minimal delay between the time the test is finished and the availability of results. Results can be accessed from any computer with network access.  Faster diagnosis and treatment: once clinicians are alerted that results are available, they can review the results and consider how that information affects the possible diagnosis.

21.  Q7A: Advantages of electronic results reporting:  Efficient consultations: more than one physician can view the images at the sample time, even if the physicians are not in the same location.  Faster medication administration: the laboratory test results for hospitalized patients are available more quickly, which makes it possible for patients to receive their medication sooner.

22.  Q7A: Advantages of electronic results reporting:  Fewer duplicate tests: since there is a computerized record of every test ordered during a patient’s hospital stay, providers will see that a test has already been performed before unknowingly ordering a duplicate test.  Enhanced analysis: results from lab tests such as glucose levels or cholesterol levels can be viewed in graphical format, making it easier to spot trends in results over time.

23.  Q7A: Advantages of electronic results reporting:  Easier retrieval: since images and results are stored on a computer, they are easy to locate and review when necessary.

24.  Sanderson, S.M. (2009). Electronic health records for allied health careers: New York, NY: McGraw-Hill.