1. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 1 Introduction to Electronic Health Records

2. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Introduction to Electronic Health Records 1. Explore the history and current use of patient health records, their importance to individuals' health, and their contribution to the healthcare system. 2. Become familiar with the content of a typical electronic health record (EHR). 3. Define documentation, and explain who documents in the medical record. 4. Discuss ownership of the health record. 5. List and explain the eight core functions of an EHR. 6. Describe the basic functions and advanced clinical decision support features of EHR software. 2 Lesson 1.1

3. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Introduction to Electronic Health Records 7. Define practice management software, and explain how it is used with the EHR system. 8. Describe advantages of EHR systems. 9. Describe disadvantages of EHR systems. 10. Discuss EHR adoption rates and who is using EHR systems. 11. Identify the roles of various healthcare professionals in implementing an EHR system. 12. Investigate various professional organizations aimed at promoting the use of EHR systems. 3 Lesson 1.1

4. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. What Is a Medical Record?  A physical collection of an individual’s healthcare information  Used throughout history to document:  Patient healthcare  Signs and symptoms  Diseases  Trends of disease 4

5. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Content of the Electronic Health Record  Each patient has his or her own record  Documentation is a vital component of the EHR  Contains:  Health information  Administrative information  Legal documents 5

6. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Clinical Information  Medication lists  Allergy lists  Immunization records  Laboratory reports  Pathology reports  Surgical reports  Hospital records  H&P  Progress notes  Radiology reports 6

7. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Administrative Information  Patient information form (PIF)  Referral letters  Consultation letters  Insurance information  Billing information  Appointment history  Diagnostic and procedure codes  Emergency contact information 7

8. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Legal Documents  Records release  Informed consent documents  HIPAA forms  Advanced directives  Living wills  Insurance authorization forms  Healthcare power of attorney forms 8

9. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Documenters of the Medical Record  Individual who is responsible for inputting information into the medical record: Documenter  Receptionist  Medical assistant  Physician (or other treating professional)  Medical biller  Structured data entry and free text documentation 9

10. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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  May be charged an administrative fee 10

11. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Electronic Health Record  Patient medical record in an electronic format  Eight core functions of an EHR system 11

12. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Eight Core Functions  Health information and data management  Results management  Order management  Decision support  Electronic communication and connectivity  Patient support  Administrative processes  Reporting and population health 12

13. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Transitioning from Paper to Electronic Records  Bush administration declared 2004-2014 “the decade of HIT”  Office of the National Coordinator of Health Information Technology (ONCHIT)  Promotes universal meaningful use of EHRs Example: Computerized physician order entry (CPOE) 13

14. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. EHR vs. EMR  Interconnected aggregate of all the patient’s health records  Data from multiple providers  Data from multiple healthcare facilities  Electronic patient record created and maintained by single provider  Component of the EHR 14

15. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Basic EHR Functions  Progress note  Documentation templates  Provider review of incoming data  Images attachment  Electronic signature insertion  Prescription (CPOE) templates  Fax and messaging  Patient reminders  Vital signs data  Importation of data  Automatic flagging  E-mail  Print 15

16. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Clinical Decision Support (CDS)  Allows providers to set protocol for specific patients and/or conditions  Based on evidence-based treatment protocols  Automated preventive care reminders  Treatment plan templates  Generates patient data reports  Documentation templates 16

17. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Practice Management Software  Administrative software used for:  Patient demographics  Billing and insurance information  Appointment scheduling  Advanced accounting procedures  These tasks are now incorporated as part of the EHR 17

18. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Administrative Source Documents 18

19. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Administrative Source Documents (Cont.) 19

20. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. EHR Advantages  Improved quality and continuity of care:  Management of chronic disease  Disaster preparedness  Increased efficiency  Improved documentation  Easier accessibility at point of care  Better security  Reduced overall expense  Job and patient satisfaction 20

21. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. EHR Disadvantages  Lack of interoperability among some products  Initial cost  Financial investment  Implementation time  Employee resistance  Regimentation  Security gaps 21

22. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Early vs. Late Adopters  The following factors affect user satisfaction:  Length of system response time  Perception of workflow logic  Ability to complete tasks  Ease of mistake correction  Training time  Availability of support staff  System effect on quality of care  Ability to convert systems to specific provider needs  Level of computer skills 22

23. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Role of the Healthcare Professional  Basic skills needed:  Knowledge of medical terminology EVERY part of healthcare is important; this is no exception  Basic typing and computer skills YES! You have to get comfortable; it takes time but you can get it  Organizational skills Prepare yourself to go paperless  Interpersonal skills Help the patients through the transition too! 23

24. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Administrative Duties  Receptionist duties  Appointment scheduling  Electronic chart creation  Purging  Entering patient data  Creating patient letters  E-mail communication  Patient education  Coordination of care 24

25. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Clinical Duties  Document treatment  Coordinate patient care  Document:  Patient history and physical  Vital signs  Progress notes (details of patient visit)  Laboratory requisitions  Prescriptions  Test results 25

26. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Billing and Coding Duties  Creation of billing statements  Assignment of procedural and diagnostic codes  Linking codes for reimbursement  Auditing  Filing patient statements 26

27. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Professional Organizations  Benefits:  Offer certification exams  Continuing education unit (CEU) opportunities  Networking  Newsletters and professional journals  Discounts on publications  Sponsor conferences, workshops, and web-based activities 27

28. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Professional Organizations (Cont.)  American Health Information Management Association (AHIMA)  American Academy of Professional Coders (AAPC)  American Association of Medical Assistants (AAMA)  American Medical Technologists (AMT) 28

29. Copyright © 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. Questions? 29