Electronic Health Record (EHR)
computerized lifelong record health care record w/ data from all sources
technology that intertwines health info from a variety of sources
every encounter an ind has w/ the health care system is documented (labs, scripts, ER visits, etc...)
New position created by EHR
Clinical Analyst Health Information Technician * Records and info coordinator
What setting may a CHERS work?
Dr office labs Ref Labs Urgent Care Centers Nursing Home Facilities Wellness Clinics Hospitals
Why were chances in technology made?
from realization that medical records were not meeting the needs of dr's & pt's. Increase in errors, rising health care costs and missing link in a pt's coordination of care.
-among most common causes of death, occur b/c:
*Lost medical records
*Miscommunicated pt request/messages
*Unreadable info due to poor handwriting
*Mislabeled lab specimens
many of these errors could be overcome if info tech were applied throughout healthcare system.
What potential does HIT have?
improve the quality of care and possibly reduce the number of deaths attributed to medical errors
What was HIPPA designed for?
enacted in 1996, designed to protect pt's private health info, ensure health care coverage when workers change or lose their jobs, and uncover fraud and abuse in health care systems.
HIPPA requires the use of electronic rather than paper ins claims?
commonly agreed upon specifications, are what helped establish the requirements necessary for agencies to follow
When did Pres Bush recommend the use of Health Information Technology (HIT)? What was the goal? Who was established to meet this goal?
In 2004, set 10 yr goal for all americans to be using EHR's, and established the OFFICE OF NATIONAL COORDINATION FOR HEALTH INFORMATION (ONCHIT) to meet this goal.
department/organ that identified standards for exchange of health info
developed certification criteria for EHR software
What does the Nationwide Health Information Network (NHIN) provide?
links medical records across the country
What 8 core functions does the Institute of Medicine suggest an EHR should include?
1) Health Info and data elements
2) Results Management
3) Order Management
4) Decision Support
5) Electronic communications and connectivity
6) Patient Support
7) Administrative Processes
8) Reporting and population management
an important business document
used to support treatment decisions
documents services provided
could also be used in court of law for evidence purposes
Electronic Medical Record (EMR)
computerized records of one dr's encounter w/ a pt over time including medical history, diagnosis, treatment and prognosis
What is the contrast between EMR's and EHR's?
EMR's reflect treatment of a pt by one dr as EHR reflects data from ALL sources that have treated and ind
Personal Health Record (PHR)
maintained & owned by the pt, pt makes decisions whether to share contents w/ their dr.
most often refers to a hospital, treats pt's w/ urgent problems that cannot be handled in another setting (hospital records keep track of time-limited episodes where dr charts reflect the ongoing health of ind) **Inpatient treatment**
refers to treatment w/o admission to hospital
What are the advantages of EHR's?
Safety Quality of Care Efficiency Cost Reduction
Will the decision of going completely electronic have a huge impact on pt efficiency?
What is a Total Conversion?
method of converting medical records all at one from paper to electronic, may be costly, but it allows all pt data to be converted at once while office can still service pt's **outsourced to an external company**
What is Incremental Conversion?
gradual change to electronic records. Advantage of this type of change are lower cost and a smoother transition due to less of an impact on the office. Disadvantages are that paper still needs to be used and not all pt data is available. **usually begins w/ pt's w/ scheduled appt***
What is Hybrid Conversion?
using a combination of paper and electron form of data. No matter what form is used dr still need to enter progress notes (most dr choose dictation/transcription process) **some may be outsourced, others in house*
What are clinical templates and what do they allow?
structured form (progress notes) that allows dr's to document pt encounters into an EHR, once it is entered it must be INTEROPERABLE: must be able to exchange info and use it in a meaningful way, therefore clinical standards are important to the details of pt info
-ensure consistency, reliability and safety
Types of Clinical Standards
-CLINICAL VOCABULARIES- set of common definitions for medical terms, they ease communications by decreasing ambiguity
-SNOMED-CT- clinical vocabulary designed to encompass all terms used in medicine
-LOINC- terms and codes used for electronic exchange of lab results and clinical observations
-UMLS- thesaurus database of medical terms
What are CLASSIFICATION SYSTEMS?
they organize terms into categories for easy retrieval, they are used for billing and reimbursement, statistical reporting and admin functions
ICD-9 and ICD-10
International Classification of Disease-standard developed by World Health Organization (WHO) contains diagnosis codes that are used in all health care settings.
DIAGNOSIS USAGE: Inpatient & Outpatient
*Number of characters: 3-5 alphanumeric
*Number of Codes: 13,000
PROCEDURE USAGE: Inpatient*
*# of characters: 3-4 numeric
*# of codes 4,000
DIAGNOSIS USAGE: inpatient & outpatient
*# of characters: 3-7 alphanumeric
*# of codes: 120,00
PROCEDURE USAGE: none
DIAGNOSIS USAGE: none
PROCEDURE USAGE: inpatient
*# of characters: 7 alphanumeric
*# of codes: 200,000
Current Procedural Terminology- list of descriptive terms and identifying codes for reporting medical services and procedures performed by health care professionals in outpatient setting, developed and maintained by American Medical Association (AMA)
CPT Code Ranges
EVALUATION & MANAGEMENT (E&M): 99201-99499 (go to dr feeling 99% leave getting high five)
ANESTHESIA: 00100-01999 (knocked out, always begin w/ 0)
SURGERY: 10021-69990 (want to feel 100%, begins w/ 1)
RADIOLOGY: (RPM, R=7, begins w/ 7)
PATHOLOGY AND LABORATORY: 80047-89356 (RPM. P=8, begins w/ 8)
MEDICINE: 90281-99607 (RPM, M=9, begins w/ 9)
Healthcare Common Procedure Coding System- level II, national codes, contains codes for products, supplies, and certain services not included in CPT. Codes are maintained by Center for Medicare and Medicaid Services (CMS)
-make it possible to transfer data from systems such as lab or pharmacy system, play crucial role in interoperability among info systems
EX: HL7, DICOM, NCPDP AND IEEE1073
Health Level 7 (HL7) Messaging Standards
(messaging standard used to send data from one application to another)-scheduling, medical record & image management, pt administration, observation reporting, financial management, public health notification, and pt care
**units of measure
**Text based reports
Digital Imaging & Communications in Medicine (DICOM) Messaging Standards
image info to workstations (x-rays, nuclear medicine) **standards that enable info exchange between imaging systems**
National Council for Prescription Drug Programs (NCPDP) SCRIPT Messaging Standards
used for retail pharmacy transactions **standard for exchanging prescription info** HIPPA requires use in retail pharmacies
The institute of Electrical and Electronics Engineers 1073 (IEEE1073) Messaging Standard
standard that provides communication among medical devices at pt's bedside (device-device connectivity)
Logical Observation Identifiers Names and Codes (LOINC) Clinical Vocabulary
contains laboratory results names, Interventions/procedures (Part A): Lab test order names
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) Clinical Vocabulary
contains lab results contents, interventions/procedures (Part B): nonlaboratory, diagnosis/problem list. anatomy
use of the language or the actual words spoken, key components are sound, words, speaking and language.
is the use of eye contact, body lang, facial expressions, or symbolic expressions to communicate a message
essential part in the process of communication w/ coworkers, pt's & visitors. Following steps to create a comfortable environment:
*refrain from making jokes or negative remarks that demean the abilities, skills or aspects of coworkers
*be patient & respectful when speaking w/ a caller that does not speak English clearly
What clinical information must be included in the patients chart?
-Vital Signs: measurement of the pt's temp, respirations, pulse and blood pressure
-Chief Complaint: A verbal account made by the pt's describing their problem
-Progress Notes: Documentation of the care delivered to a pt along w/ necessary info regarding their diagnosis and treatment
-Past Medical History: Info regarding the pt's past medical problems, conditions or surgeries
-Family History: Info regarding the medical problems of pt's family
-Social History: Info regarding the pt lifestyle such as smoking, drinking, habits, relationship status, & sexual history
-Allergies- List of the pt's allergies as well as their reactions to each one
-Medication List: Info regarding the dosage & freq of the pt's meds
-HPI (History of Present Illness): compilation of info regarding all aspects of pt's present illness
-ROS (Review of Systems): inventory of body systems in which the pt reports signs or symptoms he or she is currently having or has had in the past
-Diagnosis & Assessment: dr's conclusion regarding the cause of the pt's problem
-Plan & Treatment: dr's recommended plan of action to cure or manage the pt's condition
1) Appt scheduling, info collection
2) Pt check in, payment collection
3) Rooming, measurement Vital Signs, Pt Exam, and documentation
4) Pt checkout
5) Coding & Billing, reviewing test results
EHR's allow dr's the ability to access research, detail natioanl treatment and makes pt's w/ chronic diseases easier to manage. EHR's also allow dr's to: Order test Order Meds *Send scripts directly to pharmacy. It also has features that check for medication contraindications and errors
EHR'S and Billing and Coding
Most EHR's have features that automate the coding process, though each EHR these features may vary, these codes are checked for accuracy by a coding specialist. COMPUTER ASSISTED CODING works in a variety of ways, some may assign codes based on keywords, other analyze words/phrases and sentences. The integration of automated coding w/ the billing system facilitates claims processing
Must every service submitted for payment be documented in the pt's medical record?
YES, in order to be reimbursed, providers must document each service provided to the pt
Decision Support Tools
make the latest clinical info available at the point of care
some of the most common features inc: access to clinical info while making a diagnosis, ID'ing pt's @ risk for a specific disease and adherence to guidelines if pt monitoring is necessary. Clinical Tools will also do the following: Screen for illness and disease Identify at risk pt's *Aid w/ disease management
What are clinical guidelines?
descriptions of recommended pt care for a given condition based on the best available scientific evidence. Guidelines are based on evidence and are developed by experts in the field.
errors in prescribing medicine harm almost one million americans per yr. These errors range from prescribing a drug that interacts w/ drugs that the pt is already taking to dispensing the wrong med due to poor handwritting
the ability to e-prescribe is a feature of most EHR programs. One of the main advantages is it's ability to quickly perform safety checks, EHR programs will send alerts for potential prescription problems.
EHR in the Hospital
EHR in a hosp is extremely important to pt care. EHR compiles data from multiple clinical systems and provides a single source of info about that particular pt. EHR will also capture and store info about the pt care. It will assist in managing transactions such as: medicine prescribed, test ordered/results, and ultimately improving the quality of pt care.
Are hospital information systems complex?
What are factors that affect the care the patient receives in a hospital?
-financial aspect of a pt's stay
-lab test ordered
(all contribute to a pt's overall care in a hospital)
What are the primary benefits of a Hospital EHR?
-Unlimited access to pt's ino
-Decreased waiting time for medication delivery as well as test results
-Increased efficiency and accuracy in overall pt care
Computerized Physician Order Entry (CPOE)
an application used by dr's and other healthcare providers to enter pt care info EHR's w/ the CPOE feature also provides support tools that result in improved care and pt outcomes
Electronic Medication Administration Records (eMars)
work w/ the CPOE system to increase pt safety by electronically tracking medication administration.
The 5 rights to medication administration (eMars)
1) the right pt
2) the right medication
3) the right dose
4) the right time
5) the right route (oral or intravenous)
pre-defined groupings of standard orders for a condition, disease or procedure. These order sets make it easier to deliver quality care by eliminating errors and providing easy access to clinical content.
Adverse Drug Event (ADE)
side effects or complications from medications
the process of obtaining and updating an accurate list of all a pt's meds, is vital to the care of pt's
Personal Health Record (PHR)
the compilation of the various componets of a pt's lifelong medical history into an electronic format, may incl personal history, allergies, past immunizations, previous surgeries and much more. While the pt is usually responsible for the creation and maintenance of their personal record, they have the option to share the info w/ their provider. Educate pt's as well as those involved in their healthcare. Make it easier to monitor their health, record observations, and follow plan recommendations
Does the PHR replace the legal records of any of the patients providers?
Benefits of the Personal Health Record
PHR is proof that the medical system is evolving to fit the needs of the fast-paced, constantly changing lifestyle that many of us are accustomed to. As consumer begin to make use of this resource, bulky, time consuming forms will be a thing of the past.
What are a few of the "perks" of the PHR?
-elimination of errors made by pt filling out forms that request info the pt might not have access to
-allows pt w/ health concerns to travel w/ less worry since their records can be accessed from any location
-ensures the safety of health record located in healthcare facilities in the event of a natural disaster
Computer-based, stand alone PHR
Ind gain access their PHR using a software program that has been downloaded or installed onto their computer. Info from this type of health record is transferred to a portable memory device in order for it to be accessed from a diff location
Internet based, tethered PHR
Ind are granted access to this PHR through an outside organization, such as ins co or pt's dr. Unlike other versions of PHR, users of an internet based PHR may have limited editing capabilities. Ownership of this version of the PHR is maintained by the organization that provides access to the user. Not a true PHR. May include Patient Portals
Internet based, untethered PHR
Ind are granted access to their PHR through a web based app. Upon the creation of a username and password, the user is able to create and update info as needed
Internet based, networked and interoperable
a networked PHR allows the transfer of info of the pt's dr and of other health care org such as ins co and pharmacies. A networked PHR is continually updated. One big disadvantage of this PHR is that it does not ensure complete privacy and security.
2 parts: Title I- health ins reform; Title II- provides rights for the transfer of electronic health care data. Administration and Simplification Standards (Title II) put privacy and security mechanisms in place to ensure personal health info is kept confidential
Do HIPPA regulations apply to everyone?
no, only those who provide health care in the normal course of business and electronically transmit info. (COVERED ENTITIES, CE-health plans, providers and clearinghouses are covered entities.
ins plan that provides or pays for medical care
people or organizations that furnish, bill, or are paid for health care in the normal course business
companies that process health information and execute electronic transactions
Designated Record Set (DRS)
any item, collection, or grouping of info that includes PHI and is maintained by a CE
Electronic Protected Health Information (ePHI)
PHI that is created, received, maintained or transmitted in electronic form
Notice of Privacy Practices (NPP)
document that describes practices regarding the use and disclosure of PHI
Protected Health Information (PHI)
individually identifiable health info that is transmitted or maintained by electronic media or in any other form or medium
Treatment, Payment and Operations (TPO)
conditions under which PHI info can be released w/o consent from the pt
What is considered PHI?
-name -address -names of relatives/employers -SS# -phone/fax # -email address -health plan ID# -Account # -fingerprints -website address -medical record # -Serial # of vehicles -Photo's
Does the release of any info require authorization?
Yes, except TPO purposes
typically required for uses other than TPO
required for info about HIV, STD's and drug and alcohol abuse
Rights of Individuals
Notice of Privacy Practices describes the CE practices regarding the use and disclosure PHI. The CE must document when the pt receives such notice. Ind also have right to access and inspect a copy of their PHI, request an amendment of record, request restrictions on uses and disclosures of PHI and file a compliant about a violation w/ the Office of Civil Rights
progress notes made w/in the EHR
A standardized system of medical terminology
Current Procedural Terminology (CPT)
system of classification for services and procedures used in the outpatient setting
Digital Imaging and Communication in Medicine (DICOM)
standardized system used to transfer info between imaging systems
Health Information Technology (HIT)
use of technology as a resource to manage pt health care info
Health Level Seven (HL7)
messaging standard used to transfer data between applications
Healthcare Common Procedure Coding System (HCPCS)
system of classification for certain services and procedures not listed in CPT manual
International Classification of Diseases, Ninth Revision (ICD-9-CM)
standardized categorization of diseases
Institute of Electrical and Electronic Engineer 1073 (IEEE1073)
standardized system used to provide communication between medical devices
Logical Observation Identifiers Names and Codes (LOINC)
clinical vocabulary including terms used in the electronic exchange of lab results and clinical observations
National Council for Prescription Drug Program (NCPDP)
standardized system used to transfer prescription info
Systematized Nomenclature of Medicine Clinical Terms (SMOMED-CT)
clinical vocabulary including medical, procedural and diagnostic terms
Unified Medical Language System (UMLS)
electronic resource containing various medical terms
How is medical terminology broken down?
Into word roots, prefixes,, suffixes and combining vowels and forms. Word roots, or base words, are the foundation of the healthcare term. A SUFFIX is a word ending, a PREFIX is a word beginning and a combining vowel (usually an o) links the root to the suffix or to another root. the combining form is word root plus the appropriate combining vowel
Combining Forms and their Meanings
cerebrum (largest part of the brain)
Some suffixes of their Meanings
produced by, pertaining to producing
tumor, mass swelling
condition, usually abnormal
state of, condition
Some Prefixes and their meanings
before, in front of
excessive, above more than normal
deficient, below, under less than normal
Suffixes used to describe therapeutic interventions
process of recording
process of measurement
a visual examination
a new opening
process of crushing
Body Structure and Directional Terminology
Function: support, movement protection
Organs: Muscles, bones, joints, bone marrow
Organs: skin, hair, nails
Organs: stomach, intestines
Functions: elimination of nitrogenous waste
Organs: kidneys, bladder, ureters, urthra
O: ovaries, testes
O: blood cells
O: lymph glands, heart, vessels
F: delivers oxygen to cells
O: lungs, bronchi, trachea
F: receive/process information
O: brain, nerves, mind
F: effects changes through chemical messengers
O: pancreas, thyroid
Transitional and Directional Terms
front surface of the body
back side of the body
away from the surface
near the point of attachment to the trunk or near the beginning of a structure
far from the point of attachment to the trunk or far from the beginning of a structure
below another structure
above another structure
pertaining to the middle of nearer the medial plane of the body
pertaining to the side
lying on the back
lying on the belly
most synarthroses are immovable joints held together by fibrous tissue
amphiathroses are joints joined together by cartilage that is slightly moveable, such as the vertebrae of the spine of the pubic bone
diathroses are joints that have free movement. Ball and socket joint (hip) and hinge joints (knees) are common diathroses joints (synovial joints)
free moving joints are surrounded by joint capsules, many of the synovial joints have BURSAE-sacs of fluid that are located between the bones of the joint and the tendons that hold the muscles in place
to increase the angle of the joint
to decrease the angle of the joint
movement away from the midline
movement towards the midline
turning the palm or foot upward
turning the palm or foot downward
raising the foot, pulling the toes toward the shin
lowering the foot, pointing the toes away from the shin
moving a part of the body forward
moving a part of the body backward
revolving a bone around its axis
broken bone, most occur as a result of trauma, however some diseases like cancer or osteoporosis can also cause spontaneous fractures. Fractures can be classified as simple or compound. Simple fractures do not rupture the skin, as compound fractures split open the skin allowing for an infection to occur
the bone is crushed and or shattered
the fractured are of bone collapses on itself
the break of the distal end of the radius at the epiphysis often occurs when the pt has attempted to break his/her fall
the bone is broken and pierces an internal organ
the bone is broken and the ends are driven into each other
a minor fracture appeas as a thin line on x-ray and may not extend completely through the bone
bone is partially bent and partially broken; this is a common fracture in children b/c their bones are still soft
any fracture occurring spontaneously as a result of disease
a fracture of the epiphyseal plate in children
a traumatic injury to a joint involving the soft tissue, the soft tissue includes the muscles, ligaments, and tendons.
a lesser injury, usually the result of overuse or overstretching
when a bone is completely out of place
bone is partially out of joint
deficient in pigment (melanin)
structural protein found in the skin and connective tissue
major skin pigment
a fat cell
discolored, flat lesion (freckles, tattoo marks)
benign growth extending from the surface of the mucous membrane
groove or crack like sore
solid, round or oval elevated lesion more than 1 cm in diameter
open sore on the skin or mucous membrane
small collection fo clear fluid; blister
smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin
absence of hair from areas where it normally grows
death of tissue associated w/ loss of blood supply
bacterial inflammatory disease characterized by lesion, pustules, and vesicles