Đang tải... (xem toàn văn)
After studying this chapter you will be able to: List four medical mistakes that will be greatly decreased through the use of EHR; differentiate among electronic medical records, electronic health records, and personal health records; contrast the advantages and disadvantages of electronic health records;...
CHAPTER 12 Electronic Health Records 12-2 Learning Outcomes (cont.) 12.1 List four medical mistakes that will be greatly decreased through the use of EHR 12.2 Differentiate among electronic medical records, electronic health records, and personal health records 12.3 Contrast the advantages and disadvantages of electronic health records 12-3 Learning Outcomes (cont.) 12.4 Illustrate the steps in creating a new patient record and correcting an existing record using EHR software 12.5 Describe some of the capabilities of EHR software programs 12.6 Explain how you might alleviate a patient’s security fears surrounding the use of EHR 12-4 Introduction • Electronic health records – Eliminates duplication forms – Simply review information 12-5 A Brief History of Electronic Medical Records • Paper records becoming inadequate • Medical errors due to – Lost or misfiled records – Mishandled patient messages – Inaccurate and illegible documents – Mislabeled or illegible lab or medication orders 12-6 Apply Your Knowledge What are the four errors that stem from communication problems? ANSWER: They are: Lost or misfiled records Mishandled patient messages Inaccurate and illegible documents Mislabeled or illegible lab or medication order 12-7 Electronic Records • Electronic medical record (EMR) • Electronic health record (EHR) – Continuity of care – Reduction in errors – Decreased costs • Personal health record (PHR) 12-8 Apply Your Knowledge • Match the following: ANSWER: EHR PHR EMR PHR PHI that is collected an maintained by the patient EHR conforms to national interoperability standards PHR not a legal record EMR used by a single healthcare organization All three covered by HIPAA 12-9 Advantages and Disadvantages of EHR Government mandate steps Use all major functions of EHR Use EHR to send and receive clinical information 12-10 Advantages and Disadvantages of EHR (cont.) Clinical decisions support (in development) • • • • High priority conditions Enrolling patients in PHR Accessing comprehensive data Improving population health • E prescribing • Incentives 12-20 Other Functions of EHR Programs (cont.) • Electronic schedulers – Advantages – Disadvantage 12-21 Other Functions of EHR Programs (cont.) • Eligibility verification and referral management • Billing and coding 12-22 Other Functions of EHR Programs (cont.) • Report generators • Electronic prescriptions 12-23 Other Functions of EHR Programs (cont.) • Ancillary order integration • Patient access 12-24 Apply Your Knowledge Match the following: ANSWER: Tickler file flags allergies Electronic scheduler checks insurance coverage Eligibility verification sends an alert for follow-up care Billing and coding may send a reminder to the patient Report generator allow for electronic claims to insurance companies Prescription writer Ancillary order integration Patient access office statistics make an appointment or pay a bill submits orders to the lab Impressive! 12-25 Security and Confidentiality and EHR • Access code – Limits access – Date and time stamp • Release of information policy • Backup 12-26 Reassuring Others about EHR Security and Confidentiality • Know the confidentiality and security features • No negativity • Pamphlet explaining EHR • Show the patient his/her record • Explain access to patient 12-27 Apply Your Knowledge What does the use of access codes enable medical practice do? ANSWER: Access codes can be set to limit a person’s access to a medical record based on his/her job description They also enable a medical practice to track who has accessed a medical record as well as when they accessed it Right! 12-28 In Summary 12.1 Medical mistakes that will be greatly decreased or eliminated with EHR include: – lost or misfiled paper records – mishandled or “forgotten” patient messages – inaccurate or unreadable information in a paper medical record – mislabeled or unreadable laboratory or prescription orders 12-29 In Summary (cont.) 12.2 The electronic medical record is an electronic record of health-related information for an individual patient An electronic health record is created, managed, and gathered in a manner that conforms to nationally recognized interoperability standards A personal health record is an electronic version of the comprehensive medical history and record of a patient’s lifelong health that is collected and maintained by the individual patient 12-30 In Summary (cont.) Advantages of EHR include: (not inclusive) 12.3 – Fewer lost records – No transcription costs – Readability/legibility – Access for multiple users – Chart availability – Decreased duplication of tests Disadvantages include: – Cost – Need for training – Possible need for F/T or P/T IT personnel – Need for computer hardware/software upgrades or changes 12-31 In Summary (cont.) 12.4 The same rules apply with EHR as for paperbased medical records when initiating or documenting in a patient’s electronic health record Follow the basic steps in Procedure 12-1 for setting up a new patient EHR and 12-2 for correcting or making an addition in an existing patient’s electronic health record 12-32 In Summary (cont.) 12.5 Aside from housing patient electronic health records, many EHR programs also can perform the following functions: tickler files, specialty-specific software, electronic scheduler, eligibility verification and referral management, billing and coding capabilities, report generation, electronic prescriptions and ancillary order integration, and a patient access portal 12-33 In Summary (cont.) 12.6 Be knowledgeable of the office EHR program and never display a negative attitude about it Assist in preparing written information for the patients regarding the EHR program Show the patient his EHR, and explain how the information is entered, maintained, and kept secure Understand and be able to explain the backup process for the EHR program Understand the office access policy as it pertains to HIPAA and explain it to the patients 12-34 End of Chapter 12 The over-all point is that new technology will not necessarily replace old technology, but it will date it By definition Eventually, it will replace it ~ Steve Jobs .. .12- 2 Learning Outcomes (cont.) 12. 1 List four medical mistakes that will be greatly decreased through the use of EHR 12. 2 Differentiate among electronic medical records, electronic health records, ... records, electronic health records, and personal health records 12. 3 Contrast the advantages and disadvantages of electronic health records 12- 3 Learning Outcomes (cont.) 12. 4 Illustrate the steps in... the use of EHR 12- 4 Introduction • Electronic health records – Eliminates duplication forms – Simply review information 12- 5 A Brief History of Electronic Medical Records • Paper records becoming