Electronic Medical Records Flashcards
1
Q
EMR (electronic medical record)
A
Internal system used by a single provider or clinic
2
Q
EHR (electronic health record)
A
Comprehensive, interoperable record shared across providers
3
Q
PHR (personal health record)
A
Managed by the patient
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
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
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
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)
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
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
10
Q
Role of EMR in OT
A
- efficient documentation
- consistency and accuracy
- customizable
- patient centered-care
- patient engagement through PHRs
11
Q
Efficient documentation
A
- templates
- real time updates
12
Q
Consistency and accuracy
A
- standardized, comprehensive, complete, and accurate
- reduced errors and administrative oversights
13
Q
Customizable
A
- track progress toward specific goals
- efficiently documentation and find information
14
Q
Patient centered-care
A
- provides a comprehensive health history
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
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
Data ownership
- ensure the data in EMRs is used solely for patient care and not exploited for marketing or non-clinical purposes without consent
26
Best practices
- avoid redundancy
- maximize functionality
- ensure accuracy
- maintain data security
- use clinical decision support tools in EMRs
- track and utilize data
- increase efficiency
27
Avoid redundancy
- 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
Maximize functionality
- leverage voice-to-text tools, pre-filled templates, and quick-text shortcuts for efficiency
29
Ensure accuracy
- document during or immediately after the session to ensure accuracy and completeness
- maintain patient engagement when doing point of service documentation
30
Maintain data security
- don’t share passwords, always log out, be vigilant
31
Use clinical decision support tools in EMRs
- use automated alerts/prompts
- use built-in resources or links to clinical guidelines to ensure documentation aligns with evidence-based practices
32
Track and utilize data
- 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
Increase efficiency
- use EMR task lists to prioritize notes that need completion
34
Emerging trends (helps to INFORM out decisions, not make them)
- 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
