1.3 HIS: Patient, personal, or population records Flashcards
An HIS contains many individuals __________ of ___________ and healthcare services.
records of health
A digital patient record used within a single care setting or environment.
Electronic medical record
What does EMR stand for?
Electronic medical record
A digital patient record that can be used across more than one healthcare organization is what?
Electronic health record
What does EHR stand for?
Electronic Health Record
Name the terms for the health and healthcare terms themselves are:
electronic health record, electronic medical record, and lifelong patient record
A great deal of discussion among health professionals and health systems experts has been given the goal of creating s lifelong or longitudinal, electronic medical record for each citizen. What part of the HIS is this statement referring to?
Patient records/lifelong patient records
Explain the purpose of the lifelong patient record.
With appropriate authorization individuals or their future care givers could gain access to relevant health-related information such as immunizations, present and past major surgeries. Such records have been known by a number of name, including “ continuity of care record” and traveler’s EHR.”
Much discussion and debate has circulated about the best way to assure access to and timeliness of lifelong records, Possiblilites include:
- Putting the information on portable memory devices
- Allowing access over secure Web portals
- Encrypting the information for e-mailing among patients and caregivers
Entire health records will be held in one place for a lifetime. True or False
False. It is clear that the entire record will not be held in one place for all time.
Some kind of distributed approach will be used and this will require some kind of_______________
Master patient index.
What does the master patient index allow?
It allows computers to know where such information on a specific patient is held and that approvals are required to allow access to such information.
The patient record traditionally is two-way True or False
False. The traditional patient record is one-way. The healthcare provider inputs information and data and the patient does not see the record.
In the new patient record, the patient has access. True or False
True
May contain the information a person wisher to maintain for private use without the information being accessible to any HIS
Electronic or digital personal health record (PHR)
Explain Integrated electronic health records
- links patients with their own EHRs so they see most if not all the records that their doctors and nurses see
- patients are integrated into their data management as well as their own care
- possible because of the internet and secure Web portals
Estimate how many Americans not get their care through secure Web portal?
By some estimates, ten millions of Americans
There are four purposes of population records, name them.
- administrative and/or business operations such as reimburstments for services rendered
- Clinical groups for outcomes management
- Public health/bio-surveillance
- Research
Why would patients having absolute control over their records cause conflict?
This will interfere with bio-surveillance which is serves the needs of public health experts, who need to track communicable disease. as well as with biomedical researchers.
Name some adminstrative modules of HIS
- Master patient index
- -a database within an HIS containing unique patient identification codes for all the patients in a healthcare system - Admission, discharge, and transfer (ADT)
- -sometime called hotel
- -allows staff to admit patients, transfer them from facility to facility or room to room, etc., and discharge the patients - Scheduling and Registration
- Insurance and Billing Information
- Medical Records Coding
- DRG Assignment
Name the departmental systems within a HIS
Laboratory information systems (LIS)
-division include chemistry, hematology, etc.
-processes orders for clinical lab services and test
-connects with lab machines so pt specimens are automatically transferred to the LIS and HIS where they are made available for clinicians
Radiology information systems (RIS)
-includes patient scheduling, result reporting, and image tracking
-stores, organizes, and distributes patient radiological data
Picture archiving and communication systems (PACS)
-stores x-rays, CAT scan, ultrasound, and other types of medical images on a computer screen
Pharmacy
-receives and processes medication orders
-features pharmacy billing, inventory management, generation of medication labels, fills lists, patient profiles, and support for clinical pharm. activities
tight intergration with POE and clinical decision support systems
Name some of the clinical modules of an HIS
- Provider or physician order entry (POE)
- Clinician documentation
- Bar-code medication administration (BCMA)
- Decision support
MPI and EMPI
Master Patient Index (MPI)
-Used in a single system to uniquely identify a patient
-Assigns a Medical Record Number
—Practice Fusion
EMPI
-Used when there are multiple systems each with its own MPI
—Uses Query and Response
—Local registration systems uses EMPI to determine if patient already exists in the system
Name the ________MPI and EMPI
- Function - is embedded in registration and scheduling workflow
- Capability - help to uniquely identify a patient and prevent duplicate records
- Duplicate records represent a patient safety risk because:
- -results not available on the patient record
- -erroneous results on the patient record - Training for schedulers and registrars is critical
In a MPI and EMPI is there ownership of a duplicate record?
There must be ownership of duplicate record policy in all systems that store patient records.
Who will identify and correct duplicates?
In a hospital environment the Medical department
What does the Medical Records department do with ownership of duplicate record policy?
The Medical Records department:
- uses reports to identify duplicates
- develops written policies for corrections
- assigns responsibility for correction
The organization may use what type Scheduling
- Enterprise scheduling
- Department scheduling
- –often seen in Radiology
The capability of scheduling includes managing schedule of
- Physicians and/or staff
- Equipment
- Rooms
- –Operating rooms
Organizations may support_________-________by the patient
self-scheduling
Registration is performed by someone who is trained in
- customer service
- use of computer system
- MPI/EMPI concepts
- basic healthcare insurance concepts
What happens when a registrar checks-in a patient
- creates account and EMR encounter
- creates new patient in MPI and or EMPI if the patient does not already exist
- collects basic billing and in insurance
- front-office function in hospitals, clinics, ancillary service areas, physician offices
An ADT module includes the ability to
- admit the patient to an inpatient setting
- discharge the patient
- transfer the patient to another clinical unit
- has census capability
- has notification and interface capability
Name the financial and admin modules?
- Insurance and Billing
- –creates bills for patients and 3rd party payers
- –captures and tracks patient insurance policy information and other benefit information - Payroll
- –May or may not interface with HIS
- –often a component of HR system module
- –often has interfaces with time and attendance systems that automate the “clock punching” process - Material management
- –supports procurement of capital equipment and operational supplies and inventory functions
- –automates purchasing ordering shipping storage processes
- –assists with managing inventory - Accounts Payable
- –collection management - Gender ledger
- Budgeting
- HR
Some billing modules include
- charge master- provides information about charges to the other HIS modules
- automation of charges for prescriptions, in and out patient, co-payments, and tracking of billing caps
- event tracking- for insurance company reviews or disputes of bills
- group plan coverage information
- electronic data exchange (EDI)- capability to send transactions ot clearinghouses, which send them on to payers
An HIS may be made of ___________,_________, and/or ____________ records.
patient, personal, and or population records
