Define - mostly EHR/EMR Flashcards
(CPOE)
Computerized Prescriber Order Entry systems
PACS
an imaging system that is dedicated to the storage and
management of images (Hebda et al., 2005).
portal
a secured website that provides an authorized individual the ability to personalize the content presented online and interact with various features of the website pertinent to the user (Hebda et al., 2005).
Telehealth
delivery of health services using telecommunication technologies to clients in another location or at a distance
Called telemedicine
utilizes teleconferencing and videoconferencing technology to support the delivery of health care at a distance.
Computerized Prescriber Order Entry System
also known as computerized physician order entry system
is a system that allows a prescriber
direct entry of medication, treatment, and consultation orders for client care into a hospital information system
orders are electronically sent to the correct department for processing
(e.g., a medication order would be sent to the nurse for review, then on to the pharmacy).
–illegibility causing med errors
Point-of-care technology
a large collection of various devices, monitoring equipment, and automated medication delivery systems
handheld technologies
- PDAs
- glucometers
- electronic thermometers
physiologic monitoring systems
- hemodynamic monitors
- arrhythmia monitors
smart pumps
programmable intravenous infusion pumps
eMAR
Electronic Medication Administration Records
What is Electronic Health Record (EHR) ?
a longitudinal personal health record that is kept in digital format.
provides secure, real-time, access to a client’s health information at the point of care for the clinician.
a secure and private lifetime record describing a person’s health history and care
chronologically follows a client’s interactions with the health system across all health organizations, and across all municipal and provincial borders.
What does EHR contain?
past medical history laboratory tests treatments and procedures medication information progress notes immunizations allergies demographic information
Canada Health Infoway definition of EHR
“a complete health record under the custodianship of a health care provider(s) that holds all relevant health information about a person over their lifetime. This is often described as a person-centric health record, which can be used by many approved health care providers or health care organizations”
How can EHR be accessed?
online from many separate, compatible systems within a network
What is an Electronic Medical Record (EMR)
a practice-based computer application which provides a longitudinal collection of patient information.
legal record of what happened to a client during their medical encounter.
comprised of detailed clinical data and documentation, recorded in a standardized language
What does EMR contain?
problem list
medication list
allergy list
notes
health maintenance information
social/family history and results retrieval
(for laboratory, radiology, and other testing results)
integrated with scheduling
billing and other practice management functions
(e.g. patient registration, eligibility checking, claims submission, chart and patient tracking and referral management).
Most EMR’s include?
prescribing tool
computerized ordering
knowledge and decision-support systems
Interoperability
ability of various eHealth systems across the health system to connect with each other and exchange data.
share and synchronize patient health information within circles of care
