1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 5 Electronic Health Records

2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Evolution of Electronic Health Records Terms used to describe automated records Computerized medical record Computer-based patient record Electronic medical record Electronic health record

3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Longitudinal Patient Record A longitudinal patient record contains records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patient’s health care encounters.

4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Advantages of Manual Records Low start-up costs Training of staff is simple Requires less technically trained staff Available because there is no downtime

5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Disadvantages of Manual Records Retrieval is not easily customized. Hand-written information can be difficult to read. Difficult to abstract information Undocumented services are not easily discovered until discharge analysis occurs.

6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Advantages of Automated Records Improves access to patient information Multiple users can access patient information simultaneously and remotely Eliminates paper record storage Improves readability Timely capture of data

7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Advantages of Automated Records (Continued) Views can be customized Updates occur easily Customized retrieval of information Enhanced security Reduction in administrative costs

8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Disadvantages of Automated Records Increased start-up costs Selection and development is time consuming. Staff training is time consuming. Staff training can be costly. Technical staff is needed. User resistance can occur.

9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Transition to Electronic Records Scanning of documents Hybrid records Record transitional template

10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Regional Health Information Organization (RHIO) A RHIO is an electronic network of patient medical information gathered from multiple health care organizations in a geographic region.

11. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Stakeholders in a RHIO Hospitals Physicians Patients Health plans and insurers Public/governmental health agencies

12. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. American Recovery Reinvestment Act Areas that the act will impact include: Incentives for adoption of EHRs Advancement of Health Information Exchange New privacy regulations HIM workforce opportunities

13. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Components of Electronic Health Records Characters Fields Records Files Data Information

14. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Registration Screen

15. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Administrative and Clinical Applications Registration-admission-discharge-transfer system (RADT) Clinical applications –Patient monitoring systems –Pharmacy –Laboratory –Radiology –Nursing –Medical documentation

16. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Registration Demographic Information

17. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Clinical Information: Patient History

18. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Intake Screen at Exam

19. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Transitioning to Electronic Records Many challenges will have to be met. Health information professionals must have an understanding of automated systems. Transitions to EHRs can take years. Facilities need to establish and develop implementation plans.