Ch 5 Electronic Health Records

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Terms used to describe automated records

Computerized medical record,Computer-based patient recordElectronic medical record,Electronic health record

Longitudinal Patient record

the vision of the IOM 1991 report on the computerized 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. To create a broader patient record

Advantages of Manual Records

Low start-up costs
Training of staff is simple
Requires less technically trained staff
Available because there is no downtime

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.

Advantages of Automated Records

1.Improves access to patient information
2.Multiple users can access patient information simultaneously and remotely
3.Eliminates paper record storage
4.Improves readability
5.Timely capture of data
6.Views can be customized
7.Updates occur easily
8.Customized retrieval of information
9.Enhanced security
10.Reduction in administrative costs

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.

Transition to Electronic Records

Scanning of documents,Hybrid records,Record transitional template

Regional Health Information Organization RHIO

an electronic network of patient medical information gathered from multiple health care organizations in a geographic region. Are intended to support health information exchange

Stakeholders in a RHIO

Hospitals,Physicians,Patients,Health plans and insurers, Public/governmental health agencies

American Recovery Reinvestment Act

Feb 2009 Congress ;$19 billion Areas that the act will impact include:
Incentives for adoption of EHRs
Advancement of Health Information Exchange
New privacy regulations
HIM workforce opportunities

Components of Electronic Health Records

Characters- smallest piece of data
Fields - group of characters
Records-collection of related fields
Files- collection of related records
Data-raw facts
Information

Administrative and Clinical Applications

Registration-admission-discharge-transfer system (RADT)
Clinical applications
Patient monitoring systems
Pharmacy
Laboratory
Radiology
Nursing
Medical documentation

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.

scanner

The equipment used to capture paper record images onto electronic storage media is called a

Institute of Medicine

1991 report on CPR =longitudinal patient record

health data

health facts that are collected about a health issue

indexed

identified according to a unique id number, the scanned page is identified by a unique id number

Automated

improves access to patient information

Optical Imagining

laser technology to create an image

legal record

state law is the primary basis of the legal patient record

amendment

correction after the original document has been saved

information

data that is collected and is useful for decision making

Health information exchange

the ability for HCP to access pt information from other facilities -goal of RHIO

Patient monitoring system

collects and monitors physiologic data and records the information

Comptuerized medical records p 108

1970s-1980s term used to describe the early medical record automation

IOM and HL7

developed standards that relate to the exchange of clinical health information. NOT AHIMA

American Recovery Reinvestment Act 2009

passed by public law 111.5 for nationwide health information exchange

administrative and clinical

in all EHR applications there are 2 major components of the system which are

FALSE

A group of characters forms a file

DATA

Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols, and sounds,

True

IOM uses the term ERH in the development for exchange of health information

EHR electronic health record

AHIMA defines the -- as a computerized record of health information and associated processes

State law NOT federal law

is the primary basis for the definition of the legal patient record

RADT

a centralized database of pt demographic information in the virtual world

IOM

according to the ---- 1991 study, the health care industry's development of automated systems was fast paced.

Hybird records

are considered a transitional state until a true electronic health record can be implemented

altered

After a document is finally saved, the document must not be

pharmacy application

The type of application that includes order entry, identification of drug interactions, medical label printing,and administrative reports such as drug usage

laboratory application

An application system that includes ordering of laboratory test, the reporting of test results, and report generation is known as

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