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Understanding and Using Computerized Medical Records

Name 3 forms of EHR data

digital images, text data, discrete data

Name at least 2 medical code sets considered national standards


What is a nomenclature?

nomenclature is a system of names used in a field of science, typically created by a recognized group or authority. In an EHR, the term is used for organized lists of medical phrases and codified to help to standardize the way clinicians record information

In an EHR, what is meant by the term "finding?"

findings are codified observations that are medically meaningful to the clinician; findings pre-correlate individual medical terms into clinically relevant phrases; less granular than individual terms

Describe the difference between an EHR nomenclature and a billing code set

The difference between an EHR nomenclature and a billing code set is level of detail represented by codes. EHR nomenclatures have codes to represent not only procedures and diseases, but also symptoms, observations, history, medications, etc. EHR nomenclatures contain cross references to other code sets, billing codes sets do not.

What is one advantage of codified data over document imaged data?

When EHR data is coded, it can be used for trending, alerts, health maintenance, decision support; it can be accurately identified and electronically compared by computer. Document image data requires a human being to read the information

What is trend anaylsis?

graphs or comparison of data from different dates, tests, or events; cumulative summary reports; comparison of changes in medications or dosage to changes in blood tests

What is decision support?

providing reference information just when the clinician needs it; examples: prescription drugs, drug formularies, generic or therapeutically equivalents to brand-name drugs, evidence based guidelines and online medical references

What are alerts?

a message or reminder that is automatically generated from the data

What is health maintenance?

reminders to make patient aware when it is time for a preventative procedure or a check-up, flue shot, or other immunization

List at least 2 ways codified data in the EHR can be used to manage and prevent disease

disease management, graphic analysis, trending, preventative screening, interactive alerts

Name at least 2 benefits of having patients entering their own symptoms and history into the computer

only patient has information about what symptoms were present at outset on illness; patient is source of past medical, family, and social history; patient entered data is a more accurate reflection of patient's complaints

Name a type of decision support

defined protocols, drug formularies, medication dosing, results of case studies, standard care guidelines prepared by specialists, medical societies, or government organizations; evidence-based guidelines or medical literature

Name some advantages of electronic prescriptions

physician issues and records prescription in chart in one step; reduces errors caused by handwritten prescriptions; each medication is automatically recorded in medication list as prescription is created; renew existing prescriptions with just a few clicks

What is HL7?

national communication standard for transferring health data between disparate systems; primary standard for communication of patient demographics, lab orders, results, radiology reports, clinical observations, and other types of clinical data; Health Level Seven

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