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15 terms

Electronic Health Records/Ch. 1

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What does the acronym EHR stand for?
ELECTRONIC HEALTH RECORD
What is the definition of an EHR?
the portions of a patient's medical records that are stored in a computer system; aka electronic medical records, computerized patient records, or electronic chart.
Explain the benefits of EHR over paper charts
Legibility of Notes, Accessibility of Charts, Transcription Costs Savings, Space Savings, Eliminate Staff, Eligibility for Pay-for-performance, New Physician Recruitment, Multiple Users Use a Chart Simultaneously, Lab Results Returned Automatically, X-Ray Results Returned Automatically,
Trend Analysis
comparing data from different dates, test, or events to correlate the changes in the patient's health
Decision Support
Using interactive software tools to identify and select intelligent decisions and strategies
Alerts
reminders such as when electronic prescription system can gernarate and alert when two drugs know to have adverse interactions are prescribed for same patient
Health Maintenance
EHR system component to provide preventative health recommendations.
Describe what generally takes place from the time a patient checks in at a physician's office until the patient checks out.
...
Describe what points of the workflow are different between offices using a paper and an electronic chart.
..choosing appropriate technology; project management; configuration needs; training needs; the case for quality; and return on investment.
Describe at least the differences between inpatient and outpatient EHR systems.
"Inpatient" means that the procedure requires the patient to be admitted to the hospital, primarily so that he or she can be closely monitored during the procedure and afterwards, during recovery. "Outpatient" means that the procedure does not require hospital admission and may also be performed outside the premises of a hospital
Describe the workflow associated with an Electronic Lab Order.
the clinician's order for a blood test is transferred to a uniquely numbered laboratory requisition, which records information about the patient, the clinician, and the test to be performed.
Name at least three forces driving the change to EHR.
health and safety (IOM report/Leapfrog group) , increasingly mobile society, increased specialization, internet, readiness for change, president appoints national coordinator for health information technology
What are the four goals of the Strategic Framework created by the Office of the National Coordinator for Health Information Technology?
Inform Clinical Practice, Interconnect Clinicians, Personalize Care, and Improve Population Health.
Name some advantages of electronic prescriptions.
EP can include formulary decision support and DUR alerts to the prescribing physician, can prevent errors and save the doctor phone calls later.
What is HL7
Health Level 7-non profit organization, leading messaging standard between healthcare systems