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Electronic Medical Records
computerized records of ONE physician's encounter with a patient over time
Institute of Medicine
defines EHR to function: Health info. and data, results, orders, decision support, electronic communications, patient support, administrative, reporting and population mgt.
may be costly; allows all patient data to be converted at once while office still sees patients
gradual change to EHR, lower cost, smoother transition and less impact on office, however paper is still used and not all patient data available
common definitions for medical terms that ease communication by decreasing ambiguity
clinical vocabulary designed to encompass ALL terms used in medicine (Systemized Nomenclature of Medicine Clinical Terms): also used for anatomy, nursing, diagnosis/ problem lists, content of lab results, units of measure & immunizations (CVX, MVX)
terms and codes used for electronic exchange of lab results & clinical observations (Logical Observation Identifiers Names & Codes)
ICD-9 and ICD-10
international classification of diseases developed by the World Health Orgnanization (WHO)
ICD-9 vs. ICD-10
(International Classifications of Diseases)
ICD-9 has 3-5 alphanumeric for inpatient and outpatients with 3-4 numeric procedure codes; ICD-10 has 3-7 alphanumeric for inpatient & outpatients with 7 alphanumeric procedure codes
current procedural terminology; maintained by the AMA (american medical assoc.) descriptive terms & codes for reporting medical services & procedures performed in an outpatient setting (evaluation, anesthesia, surgery, lab, medicine)
Healthcare Common Procedure Coding System: codes for products, supplies & services not included in CPT maintained by the Centers for Medicare/Medicaid Services (CMS)
Health Level 7: messaging standards for scheduling, medical record/image mgt., pt. admin., observations, financial mgt., public health notification and pt. care; also for pt. demographics
Health Insurance Portability & Accountability Act
Title I: health insurance reform: rights for the transfer of elctronic healthcare data
Title II: administration & simplication standards put privacy and security in place to ensure confidential PHI
Patient chart includes:
Vital Signs, Chief Complaint, Progress Notes, Past Medical Hx, Family Hx, Social Hx, allergies, medications, HPI (hx of present illness), ROS (review of systems), Diagnosis & assessment, treatment plan
a feature of most EHR's-- Advantages: auto checks for drug interactions, safety checks, and will send alerts for potential Rx problems
Primary benefits of EHR
unlimited access to pt. info., decreased waiting for medication delivery and test results, increased efficiency & accuracy
Computerized Physician Order Entry: app to enter pt. care info and provides support tools which results in improved pt. & outcomes
electronic medication administration record & scheduling: to track meds going in and out of a pharmacy/hospital, etc. (helps with errors and ADE-adverse drug events)
personal health record: a patient's lifelong medical hx in electronic format (personal hx, allergies, immunizations, surgeries, etc.). This does NOT replace legal records of providers
Types of PHR
1. Computer based, stand alone: downloaded software transferred to a portable memory device in order to access from another location
2. Internet based, tethered: access provided by insurance co. or provider; limited editing ownership maitained by access organization
3. Internet based, untethered: web based app involving username/password, editing as needed
4. Internet based, networked/interoperable: networked between insurance, pharmacies, other healthcare organizations, continually updated--disadvantage: does not ensure complete privacy/security
designated record set: group of info. that includes PHI and is maintained by a covered health entity
these are conditions regarding treatment, payment and operations--conditions under which PHI can be released without consent
defined as: name, address, Names of relatives & employers, SS#, Ph and fax #, email address, Health plan id#, account #, fingerprints, website address, MR#, serial numbers of vehicles and photos
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