2. HIS Fundamentals Flashcards
what is the definition of EMR, EHR and PHR& their levels
EHR = national –> more than ONE
EMR = institution –> accessed by authorised clinicians in ONE healthcare org
PHR = personal –> multiple sources accessed by INDIVIDUAL
what is CPOE
computerised physician order entry (CPOE)
- replaces hospital paper based ordering system
- record instructions for patient treatment
- trigger safety alerts
benefits:
- full range of orders
- medication record
- communication of successive personnel
what are some similar systems to CPOE
- pharmacy information system
- pharmaceutical decision support system
- electronic prescription
what is eMAR
electronic Medication Administration Record
- automates documents for administration of medication into certified EHR tech using tracking sensors (RFID, barcodes)
how does communication occur between HIS
- every dept may have their own version of a HIS and standards e.g. CPOE and PACS
- all are integrated via EHR
- governed by HL7 & DICOM
what differentiates PHR from EMR & EHR
Whereas an electronic health record (EHR) is a computer record that originates with and is controlled by doctors, a personal health record (PHR) can be generated by physicians, patients, hospitals, pharmacies, and other sources but is controlled by the patient.
what does EHR connect to
Patient Management. The patient management component facilitates the capture, storage and retrieval of up-to-date information related to new patients. …
Clinical Component. …
Secure Messaging and Alerts. …
Financial Dashboards. …
Revenue Cycle Management (RCM)
what are the benefits of EHR
- reminders & alerts
- compliance
- reduced errors
- accessibility
- cost reduction
- efficiency
what is the usability value of EHR
systems communicate with each other rather than department personnel manually exchanging information
name some EHR trends
basic without clinician notes –> basic with clinician notes –> comprehensive
- moving to cloud
- doing EHR analytics
- using AI
- mobile –> tablets & smartphones
why is blockchain technology applicable to PHR
- it uses ledgers
- data is distributed and available everywhere but only the owner has the key
- record of every time a ledger is accessed
what is SDPR is it an EHR
yes it’s an EHR
what is included in SDPR
- PAS = patient admin system
- EMR = electronic medical record
- LIMS = laboratory information manegement system
what is HealtheNet
- eHealth NSW program that connects disjointed systems
- NSW clinicians can get access to NSW LHD EMR & EHR and PHR
- consistent and accurate info to deliver best care
is eMR institution based, and what is eMR2
yes, EMR2 is integration of all EMRs implemented across the state
what are 2 goals of the australian digital health strategy
interoperability & data quality
what is interoperability
the ability of IS to communicate, exchange and utilise exchanged data while still preserving the meaning and context of data
what is semantic interoperability
preserving the original meaning of the data sources
what is the purpose of a data standard
ensuring every system can communicate
what is the relationship between data standards and DQ
- seamless exchange
- confidence in meaning & context
- less mistakes
- better quality patient care
- patient safety
what are the different types of data standards development processes
- adhoc: no formal adoption process
- defacto: vendor or other has large mkt segment
- government mandated: legislative
- consensus: volunteers from different orgs to come together to reach a formal agreement
what are some data interchange standards
- HL7
- DICOM (digital imaging and communications in medicine)
from ISO (International organisation for standardisation) - ANSI (american national standards institute)
what is the purpose of HL7
- system integration & interoperability
- tools to build standards
- messaging & document standards
- EHR functional models & profiles
what are some primary standards of HL7
- version 3 messaging standard
- CDA = clinical document architecture
- FHIR = hl7 fast healthcare interoperability resources
- context managment spec
examples of HL7 CDA
- DisplayName shall be accurate
- Identifiers shall be unique
- each entry shall contain at least one text reference
what is FHIR
fast healtchare interoperability resorces
interoperability standard to facilitate the exchange of information between anyone involved in the HC ecosystem
what are some non-priority HL7 standards
- mobile health
- CCD (continuity of care document)
what PHR developer has integrated HL7
Apple
what is NCVHS & what do they recommend
- national committee on vital & health stats
- systematised nomenclature of medicine
- federated drug technologies e.g. RxNorm
what is SNOWMED
Systematized Nomenclature of Medicine Clinical Terms
- comprehensive clinical terminology to facilitate electronic storage & retrieval of detailed clinical info
- facilitates efficiency and consistency
what is NCIRD and is it compatible with HL7
- national centre of immunization & respiratory disease developed a CVX (clinical vaccines administered table)
- yes
what are some HL7 DQ requirements
- unique patient ID
- confidential & secure authentication & accountability
- interoperability across systems
what are some causes of poor quality data
- unclear data definitions
- programming errors
- no or lacking test cases
do EMRs require structured data input and why
no, because patient data can come from anywhere e.g. overseas
how is dq improved using prevention
- data checks
- user friendly data entry forms
- training
how is dq improved using detection
- dq audit e.g. ask clinicians and registrars
- review of data collection protocols/procedures
- automatic data checks
how is dq improved using improvement methods
- provide users with dq reports
- give feedback of dq with results and recommendations
- implement identified system changes
what is the process for improving dq
prevention –> detection –> improvement
