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Application Of OT > Electronic Medical Records > Flashcards

Electronic Medical Records Flashcards

1
Q

EMR (electronic medical record)

A

Internal system used by a single provider or clinic

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2
Q

EHR (electronic health record)

A

Comprehensive, interoperable record shared across providers

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3
Q

PHR (personal health record)

A

Managed by the patient

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4
Q

1960s: first computerized health records

A
  • very basic, expensive, and accessible only to a few institutions
  • primarily researched-focused and used in large hospitals to centralize patient data for specific programs
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5
Q

1970s-1980s: early adoption

A
  • development of larger mainframe-based systems by hospitals
  • adoption of computers for billing and administrative tasks begins in healthcare
  • high costs, lack of standardization, and mínale integration between system
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6
Q

1990s: shift toward standardization

A
  • focus on creating unified standards for medical records
  • widespread adoption of personal computers makes EMRs more feasible for smaller clinics
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7
Q

2000s: regulatory push for EMR adoption

A
  • establishment of the Office of the National Coordinator for Health Information Technology (ONC) by the U.S. Department of Health and Human Services
  • HITECH Act (Health Information Technology for Economic and Clinical Health) provides financial incentives for EMR adoption
  • surge in private companies creating commercial EMR platforms (ex: Epic, Cerner)
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8
Q

2010s: widespread implementation

A
  • introduction of patient portals for increased client engagement
  • integration of clinical decision support tools (ex: alerts for drug interaction)
  • improved data sharing across providers, patient outcomes, and billing processes
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9
Q

2020s: current trends and future directions

A
  • focus on interoperability: systems communicating seamlessly across providers
  • Integration of artificial intelligence (AI) for predictive analytics and enhanced clinical support
  • risk of telehealth and its incorporation into EMR platforms
  • data privacy and cybersecurity threats
  • balancing automation with personalized care
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10
Q

Role of EMR in OT

A
  • efficient documentation
  • consistency and accuracy
  • customizable
  • patient centered-care
  • patient engagement through PHRs
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11
Q

Efficient documentation

A
  • templates
  • real time updates
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12
Q

Consistency and accuracy

A
  • standardized, comprehensive, complete, and accurate
  • reduced errors and administrative oversights
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13
Q

Customizable

A
  • track progress toward specific goals
  • efficiently documentation and find information
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14
Q

Patient centered-care

A
  • provides a comprehensive health history
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15
Q

Patient engagement through PHRs

A
  • PHRs empowering patients to take an active role in their care
  • PHRs allow patients to view their progress, scheduled appointments, and goals
  • providing visual progress reports enhances motivation and adherence to treatment plans
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16
Q

Improved interdisciplinary care and communication

A
  • access to shared data
  • team collaboration
17
Q

Access to shared data

A
  • each member can view relevant records from other providers
  • reduces the risk of redundant treatments and enhances continuity of care
18
Q

Team collaboration

A
  • EMRs facilitate communication between all disciplines, improving the coordination of interventions
  • integrated messaging tools allow therapists to discuss patient care plans directly within the EMR system
19
Q

Legal considerations

A
  • HIPPA compliance
  • audit trails
  • security threats and cybersecurity
20
Q

HIPPA compliance

A
  • EMRs ensure that documentation is stored securely and accessed only by authorized personnel, protecting client confidentiality
  • patients have legal right to request access to their medical records
  • consent forms and authorizations must be obtained, stored, and accessible
  • patient information should be shared only with providers directly involved in the patient’s care and only when it is relevant to their treatment and clinical needs
  • EMR systems implement safeguards such as encryption, password protection, and role-based access
  • therapists are ethically obligated to document accurately and truthfully
21
Q

Audit trails

A
  • every entry in an EMR is time-stamped and associated with a specific user, creating accountability and reducing the risk of malpractice
22
Q

Security threats and cybersecurity

A
  • hacking, phishing attacks, and ransom ware are significant risks to EMR systems
  • therapists must be vigilant about suspicious emails, unsecured networks, or weak passwords
  • multi-factor authentication and routine system updates help mitigate risks
23
Q

Ethical considerations

A
  • balancing efficiency and personalization
  • data ownership
24
Q

Balancing efficiency and personalization

A
  • while templates and checkboxes save time, they may reduce the depth and personalization of notes
  • therapists must balance efficiency with meaningful documentation
25
Q

Data ownership

A
  • ensure the data in EMRs is used solely for patient care and not exploited for marketing or non-clinical purposes without consent
26
Q

Best practices

A
  • avoid redundancy
  • maximize functionality
  • ensure accuracy
  • maintain data security
  • use clinical decision support tools in EMRs
  • track and utilize data
  • increase efficiency
27
Q

Avoid redundancy

A
  • EMRs often have templates or auto-fill features (while useful, avoid copying and pasting identical text across sessions without meaningful updates)
  • avoid relying on pre-filled fields without reviewing or updating them, as they may lead to outdated or incorrect information
28
Q

Maximize functionality

A
  • leverage voice-to-text tools, pre-filled templates, and quick-text shortcuts for efficiency
29
Q

Ensure accuracy

A
  • document during or immediately after the session to ensure accuracy and completeness
  • maintain patient engagement when doing point of service documentation
30
Q

Maintain data security

A
  • don’t share passwords, always log out, be vigilant
31
Q

Use clinical decision support tools in EMRs

A
  • use automated alerts/prompts
  • use built-in resources or links to clinical guidelines to ensure documentation aligns with evidence-based practices
32
Q

Track and utilize data

A
  • use the EMR’s graphing or reporting features to track progress toward therapy goals
  • leverage aggregated EMR data to identify patterns and inform evidence-based interventions across clients
33
Q

Increase efficiency

A
  • use EMR task lists to prioritize notes that need completion
34
Q

Emerging trends (helps to INFORM out decisions, not make them)

A
  • AI-powered clinical decision support
  • predictive analytics for outcome tracking
  • personalization of intervention
  • telehealth integration
  • increased interoperability
  • voice recognition to dictate notes in real time
  • wearable device integration
  • EMRs integrated with augmented and virtual reality
  • improved user experience

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