Electronic Health Record (EHR) Systems Flashcards
Difference between EMR and EHR
EMR = digitized medical records
EHR = same as EMR but built to share info with all healthcare providers
HITECH act of 2009
Health Information Technology for Economic and Clinical Health Act
Authorized incentive payments through medicare and medicaid to clinicians and hospitals that use EHRs in a “meaningful way” that significantly improves clinical care
[in 2010, docs had to prove they had met 25 functional objectives to be considered “meaningful users” and if not, there were penalties including cuts to medicare payments for those not implementing EHR]
Stages of Meaningful Use (MU)
Stage 1 — Data capture and sharing (2011)
Stage 2 — Advance clinical processes (2014-2017)
Stage 3 — Improved outcomes (2018)
_____ ____ refers to the utilization of certified EHR technologies by health care providers in ways that measurably improve health care quality and efficiency
Meaningful use
[the ultimate goal is to bring about healthcare that is patient-centered, evidence-based, prevention-oriented, efficient, and equitable]
What are some clinical quality measures that have been added to the meaningful use criteria?
Capability to contact provider electronically (i.e, “patient portal”)
Clinical decision support tools
Patient adherence to things like medications, lab monitoring, etc.
What are some reasons as to why we are in an economic healthcare crisis?
As premiums go up, the overall amount of money that can be utilized for administrative, medical, and other costs declines, as pts cannot afford the premium
In addition, as there are increases in population size, morbidity, EHR implementation, and technology advances, the overall costs of administrative, medical, etc. increase — further exacerbating the problem
Describe the fee-for-service model of healthcare
Volume-based, not value
Physician is paid when pt is seen
Describe the Merit-Based Incentive Payment System (MIPS)
Standardizes measures (evidence-based)
Incentivizes care that focuses on improved quality outcomes
Increases access to better care
Enhanced coordination through a pt-centered approach
Improved results
What is MACRA?
Medicare Access and CHIP Reauthorization Act of 2015
CMS stated that MACRA enacts a new payment framework that rewards healthcare providers for giving better care instead of more service
Disadvantages to EHRs
Too much typing Inadequate traning Can’t capture personal moments Too many alerts Too much discrete data vs. free text Too much time gathering data
Shortcuts on EHR
Dictation Templates/quick text EHR customization Scribes Workflow modifications Cost and accuracy, capability
Etiquette when using EHR
Introduce yourself
Sit down
Get initial hx first, then enter info on computer
Invite pt to look at computer w/ you
When appropriate, turn away from computer
Don’t put computer b/w you and pt
Expectations for medical students use of EHR
Must have own unique login/password to chart on preceptor’s behalf
Contribute meaningful data to EHR with inclusion of student note
Enter data into the appropriate fields in the EHR — including rationale, data search, protocols, templates, decision support, etc.
Have all notes reviewed, edited, and signed by supervising doc with feedback given
Review screening and prevention recommendations and bring to attention to supervisor
Become familiar with CPT/ICD-10 codes, billing, order entry, E-prescribing, Patient Centered Medical Home metrics, Query functions
In the old system per medicare and medicaid services guidelines (CMS), the attending physician had to verify and redocument the HPI, perform and redocument the PE, and medical decision making activities of service; the attending was able to simply “accept” the student’s documentation of ROS or PMH, PSH, Soc Hx and Fam Hx.
The Centers for Medicare and Medicaid Services (CMS) is revising the Medicare Claims Processing Manual to update policy on Evaluation and Management documentation to ….
Allow teaching physician to verify any student documentation in the medical record, rather than redocumenting
Students are also now able to document services in the medical record, but the teaching physician must verify in the medical record ALL student documentation
The teaching physican must personally perform (or re-perform) the PE and medical decision-making activities being billed, but may verify any student documentation of them in the medical record rather than re-documenting this work
Legal/ethical EHR concerns regarding medical students
Templates — too easy to leave normal hx, ROS, ,or exam pre-populated
Note cloning — all notes look the same
Increased liability of students document info in chart (erroneous info, info that attending ignores, juries might be confused, etc.)
