Advantages of total conversion
-all patient data are converted at once and are available in the EHR
-office staff members do not need to take time away from regular tasks to manually enter data
Disadvantage of total conversion
-the conversion of unnecessary data, such as data for patients who will not visit the practice again
-a higher error rate because of lack of in-house oversight of conversion
an alternate approach to the total conversion strategy is to convert the data incrementally, based on the assumption that electronic access to the record is required only for those patients for whom appointments are scheduled.
Advantages of an Incremental approach are:
-cost savings because the conversion is done by the office staff
-a smoother transition with less impact on day-to-day practice operation because the data are converted gradually
Disadvantages of an incremental approach are:
-occasional use of archived paper charts may be necessary
-not all patient data are available in the EHR at once
many practices use a combination of strategies. in a hybrid approach some records may be outsourced, and others are converted in-house.
Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT)
is a comprehensive clinical vocabulary designed to encompass all the terms used in medicine, includong procedures and diagnoses
Healthcare Common Procedure Coding System (HCPCS) level II
contains codes for products, supplies, and certainservices not included in CPT.
Current Procedural Terminology (CPT)
develpoed and amintained by the American Medical Association (AMA), is a listing of drescriptive terms and identifying codes for reporting medical services and procedures performed by health care providers in outpatient settings.
structured progress notes that physicians use to document patient encounters in an EHR.
providers dictate using a microphone connected toa desktop or laptop computer equipped with special voice recognition software.
advantages of voice recognition
-transcription cost are reduced
-information is available in medical record in less time than with standard dictation and transcription methods
-physicians are comfortable with the approach because it is similar to traditonal dictations.
disadvantages of voice recognition
-the possibility of an unacceptable accuracy rate if interferences such as background noise is present
-the need for the physician or an assistant to review and edit the files
-the costs associated with purchasing voice recognition equipment and software
are the hardware devices used to access the electronic health record software as well as the word processing, practice management, and other software.
is a fixed, hradwired computer that stays in one location and cannot be easily moved from room to room.
is a third type of workstation that contains voice recogniton software and that also has built-in handwriting software