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
5.Timely capture of data
6.Views can be customized
7.Updates occur easily
8.Customized retrieval of information
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
Administrative and Clinical Applications
Registration-admission-discharge-transfer system (RADT)
Patient monitoring systems
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.
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 facts that are collected about a health issue
identified according to a unique id number, the scanned page is identified by a unique id number
improves access to patient information
laser technology to create an image
state law is the primary basis of the legal patient record
correction after the original document has been saved
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
A group of characters forms a file
Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols, and sounds,
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
a centralized database of pt demographic information in the virtual world
according to the ---- 1991 study, the health care industry's development of automated systems was fast paced.
are considered a transitional state until a true electronic health record can be implemented
After a document is finally saved, the document must not be
The type of application that includes order entry, identification of drug interactions, medical label printing,and administrative reports such as drug usage
An application system that includes ordering of laboratory test, the reporting of test results, and report generation is known as