Electronic Health Records Flashcards
Electronic Health Record (EHR)
Electronic record of health-related information on an individual
Conforms to nationally recognized interoperability standards
Can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
Qualified EHR
Includes patient demographic and clinical health information
AND
has the capacity to:
provide clinical decision support
support physician order entry
capture and query information relevant to health care quality
able to exchange electroni health information with and integrate such information from other sources
Functions of EMR
- Captures and enables use of data at POC
- Health Information Exchange
- Quality measurement, reporting, and improvement
- Supports clinical decision makeing
- Collects and integrates source data
3 Components of MU incentive program
- Certification Program whereby EHR technology is tested and certified as meeting standards and criteria.
- Standards and Criteria that certified EHR technology must meet
- Objectives and measures for earning incentives
Certification of EHRs
Oversight by ONC (Office of the National Coordinator for Health Information Technology)
Testing Laboratories are accredited by
*Americant National Standards Institute (ANSI)
*National Voluntary Laboratory Accrediaton program (NVLAP)
Standards that EHRs must meet
Address specifications for exchanging health information content,
vocabularies for representing health informaiont,
protection of health information created, maintained, and exchanged by EHR technology
Objectives and meausre for earning incentives
Defined by Centers for Medicare and Medicaid Services (CMS)
Stages of MU implementation
2011: Data capture and sharing
2013: Advanced clinical processes
2015: Improved outcomes
Priorities for adoption of EHR Technology
- Improve quality, safety, efficiency, and resude health disparities
- Engage patiens and their families in their healthcare
- Improve care coordination
- Improve population and phblic health
- Ensure adequate privacy and security protections for personal health information
Specific outcomes for EHR
- Improve quality of healthcare
- Enhance patient safety
- Support health maintenance
- Increase productivity
- Reduce hassle factors
- Support revenue enhancement
- Support predicitive modeling
- Maintain patient confidentiality
Improving quality of Health care with EHR
Data availability
Links to knowledge sources
Enhancing paitient safety with EHRs
Context-sensitive reminders and alerts clinical decision support automated surveillance Chronic disease managment Drug/device recall capability
Support of health maintenance by EHRs
Preventive care and wellness with reminders Health summaries Tailored instructions Educational materials home monitoring/tracking
Increased productivity with EHRs
Data capture and reporting formats tailored to users
streamlined workflow supprot
patient-specific care plans, guidelines, and protocols
Reduction of hassle factors with EHRs
Improve satisfaction for clinicians, consumers, and caregivers by managing:
- scheduling
- registration
- referrals
- medication refills
- work queues
- auto generation of administrative data
Support of revenue enhancement by EHRs
Eligibility and benefit information Cost-efficiency analysis Clinical trial recruitment Rules-driven coding assistance External accountability reporting/outcome mx Contract managment
EHR System components
Hardware Software People Policy Process
4 main categories of information systems that comprise the EHR
- Sources systems that collect data, including administrative, financial, and clinical
- Core clinical systems that enable use of data at the point of care
- Supporting infrastructure that integrates data from applications internalk to a given care delivery organization
- Connectivity systems that support the integration of data across different organiatons and with patients or their caregivers
MPI
Master patient index
R-ADT
Registration - Admission, Discharge, Transfer
PMS
Practice Management System (ambulatory)
PFS
Patient Financial Services
HIM
Health Information Management
EDMS
Electronic Document Management Systems
DIMS
Document Imaging systems
ED/CM
Electronic Document content management
OC/RR
Order Communication/Results Retrieval Systems
LIS
laboratory information system
RIS
Radiology Information System
PIS
Pharmacy Information System
PACS
picture archiving and communications systems
POC charting systems and types of data
Clinical documentation systems
Structured data = discrete data : data tht have been predefined in a table or checklist or uses drop down menus
Unstructure data = narrative data
POC charting systems
Smart phones Tablets wireless on wheels /workstations on wheels laptops PDAs
CPOE
computerized provider order entry
CCR
Continuity of Care Record
CCD
Continuity of care document rendered in xml or pdf using HL7 Clinical docuemtn Architecture
CDR
Clinical Data Repository
Relational database intended to support direct care delivery functions
Can process many kinds of transactions
CDS
Clinical Decision Support
Software that porocesses infoirmation to provide assistance with making a clinical decision
Embedded in EHR
CPT
Current Procedural Terminology
Executive decision support
Standalone system that analyzes a large volume of aggregated data and provides trending information Typically retrospective Quality miprovement Procutivity Staffing
CDW
Clinical Data Warehouse Advanced component of EHR Database that has been optimized for analysis Used for data mining Used for predictive modeling
PHR
Personal Health Record
Systems designed to suppport patient-entered data.
May be standalone or linked to provider
Telemedicine
Use of medical informtion exchanged from one site to another via electronic communications to improve,l maintain, or assist patients health status.
Closely associated with telehealth
May include home monitoring
HIE
Health Information Exchange
Seamless exchange of health informaton across disparate organizatons.
May be part of a format HIO - Health Information Organization
Maybe local, regional, or state
Supports the development of the nationwide health infomation network (NWHIN)
AHIMA
American Health Information Management Association
Integration
The task of linking inforamtion system comp0onents together to that they communicate and act as a uniform entity.
Information systems built on same platform are built to be integrated
Other wise systems integrators use various programming and process techniquest to integrate disparate systems.
Interoperability
The ability of differen information systems and softare applications to communicate and exchange data
Electronic Medical Record (EMR)
Electronic record of health related information on an individual
Created, gathered, managed, and consulted by authorized clinicians and staff withon one healthcare organization
