RES: MODULE 3 PART 2 Flashcards
The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts
CLINICAL DECISION SUPPORT (CDS)
A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions
CLINICAL DECISION SUPPORT SYSTEMS (CDSS)
Electronic results can be displayed automatically for care providers to improve effectiveness and efficiency of treatment while reducing cost of care by eliminating duplicate testing
RESULTS MANAGEMENT
Provides physicians and other providers the ability to place orders via the computer from any number of locations and adds decision support capability to enhance patient safety
Computerized Provider Order-Entry (CPOE) / Computerized Physician Order-Entry / Computerized Provider Order Management (CPOM)
This provides for effective and efficient patient care through decision making tools that are not currently available in paper-based health record systems
CLINICAL DECISION SUPPORT SYSTEMS (CDSS)
Health record should not be just a simple repository of patient care data
CLINICAL DECISION SUPPORT SYSTEMS (CDSS)
Assist healthcare providers in the actual diagnosis and treatment of patients
CLINICAL DECISION SUPPORT SYSTEMS (CDSS)
Review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends before problems become evident
CLINICAL DECISION SUPPORT TOOLS
Can recall relevant diagnostic criteria and treatment options on the basis of the data in the records
CLINICAL DECISION SUPPORT TOOLS
Supports the physician as he or she considers various diagnostic and treatment alternatives
CLINICAL DECISION SUPPORT TOOLS
WHATARE THE INSTITUTE OF MEDICINE KEY CAPABILITIES OF EHR SYSTEMS (EVOLUTION OF EHRS IN HOSPITALS)
- Health information and data
- Results management
- Order entry management
- Decision support
- Electronic communication and connectivity
- Patient support
- Administrative process
- Reporting and population health management
Providers have voiced out the lack of interoperability because it greatly limits the progression of specialties such as pain management
LACK OF INTEROPERABILITY
Stymies efforts of information governance and information sharing between organizations
LACK OF INTEROPERABILITY
It must be improved to create standardization for data that can or will be staged for a data warehouse
LACK OF INTEROPERABILITY
WHAT ARE THE USES OF EHR
- Reduce medical errors
- Provide more effective methods of communicating and sharing information among clinicians
- Lower national health care costs, better
management patient medical records - Improve coordination of care and health care
quality condition, response to care, treatment course, and any deviation from standard treatment/reason)
WHATARE THE 2 TYPES OF DATA IN HEALTH RECORD
- CLINICAL DATA
- ADMINISTRATIVE DATA
Documents the patient’s medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided
CLINICAL DATA
Include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information
ADMINISTRATIVE DATA
WHATARE THE 4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION?
- Facility- specific standards
- Licensure requirements
- certificate standards
- accreditation standrds
4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:
- Standards might be found in facility policies and procedures and, when a facility has an organized medical staff in the medical staff bylaws, rules, and regulations
- Facility-specific guidelines govern the practice of physicians and others within a specific organization
FACILITY-SPECIFIC STANDARDS
4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:
Before they can provide services, most healthcare organizations must be licensed by government entities such as the state or country in which they are located and must maintain a licenses as long as care is provided
LICENSURE REQUIREMENTS
4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:
1.Government reimbursement program standards are applied to facilities that choose to participate in federal programs such as Medicare and Medicaid
2. These standards are titled conditions of participation or conditions for coverage. Facilities are said to be certified if the standards are met
CERTIFICATION STANDARDS
4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:
Accreditation is the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization
ACCREDITATION STANDARDS
The following are description of alternatives aside from the four main sources for standard of documentation guidelines:
- State regulating agencies
- Medicare and Medicaid programs
- Accreditation organizations
- The joint commission
- Document current observations, outcomes and progress
- Entries should be consistent with documentation in the record (e.g. flow charts)
- If the documentation is contradictory, an explanation should be included
CONSISTENCY
State the facts about patient care and treatment and avoid documenting opinions:
OBJECTIVE DOCUMENTATION
If other patient(s) are referenced in the record, do not document their name(s) instead reference their patient number(s) instead
REFERENCING OTHER PATIENTS
Documentation entries in the patient record are considered permanent and policies and procedures should be established to prevent falsification of and tampering with the record
PERMANENCY
- Select white paper with permanent black printing to ensure readability of paper-based record, not photocopies
- File original documents in the patient record, not photocopies
- Avoid using labels on reports because they can become separated from the report
PHYSICAL CHARACTERISTICS
- Be sure to document specific information about patient care and treatment. Avoid vague entries
- Incorrect: Eye exam is normal
- Correct: Eye exam reveals pupils equal, round
and reactive to light
SPECIFICITY
PATIENT RECORD DOCUMENTATION GUIDELINES: Entries should be documented and signed (authenticated by the author)
AUTHENTICATION
PATIENT RECORD DOCUMENTATION GUIDELINES: If the patient’s condition changes or significant patient care issue develops, documentation must reflect this as well as indicate follow-through
CHANGE IN PATIENT’S CONDITION
- Significant information related to patient’s care and treatment should be documented (e.g. patient
- Evidence of the patient’s family participation in decision making
- Evaluation reports from each service
- Reports of staff conferences
- Progress reports
- Correspondence related to the patient
- Release forms
- Discharge summary
- Follow-up reports
COMPLETENESS
Focus of services in physical medicine and rehabilitation is increasing a patient’s ability to function independently within the parameters of the individual’s illness or disability
REHABILITATION SERVICE DOCUMENTATION
Documentation requirements for rehabilitation facilities vary because facilities range from comprehensive inpatient care to outpatient services or special program
REHABILITATION SERVICE DOCUMENTATION
What are the document standards?
- Patient identification data
- Pertinent history, including functional history
- Diagnosis of disability / functional diagnosis
- Rehabilitation problems, goals, and
prognosis - Reports of assessments and program plans
- Reports from referring sources and service
referrals - Reports from outside consultation and
laboratory, radiology, orthotic and prosthetic
services - Designation of a manager for patient’s
program
A computer software with a licensing provision that enables the users to modify, utilize, and distribute unmodified or modified version
OPEN-SOURCE SOFTWARE (OSS)
Has freely available source code
OPEN-SOURCE SOFTWARE (OSS)
Anyone can modify and distribute the code without the licensing fees, as defined in the software’s license unlike proprietary software
OPEN-SOURCE SOFTWARE (OSS)
No system is free. All systems will have implementation and maintenance costs
OPEN-SOURCE SOFTWARE (OSS)
what are the 5 systems of open source EHR
- OpenMRS
- BAHMNI
- GNU HEALTH
- OPEN VISTA AND WORLDVISTA
Is a community-driver EHR platform supporting over 8.7 million active patients in 3,307 sites across over 64 countries
OpenMRS
There are atleast five national implementation with hundreds of sites each, including Kenya, Mozambique, the Philippines and Uganda. OpenMRS follows international standards, such as FHIR, is modular so functionality can be added through modules, and has customizable forms and a data dictionary
OpenMRS
Meant for a clinical implementation and has practice management functionality
OpenMRS
Consists of OpenMRS for clinical functionality, OpenELIS for laboratory management, dcm4chee for imaging and OpenERP or odoo for practice management and logistics
BAHMNI
It is implemented in over 8 countries and
has a list of vendors or implementation
partners that can be hired to provide
BAHMNI
Is an EHR and laboratory management system that has been adopted by the United Nations University and is an official project of GNU
GNU HEALTH
Has functionality for many areas of a hospital, GNU Health’s forms and data dictionary cannot be modified
GNU HEALTH
Developed by the US Department of Veterans Affairs
OpenVistA and WorldVistA
Used in more than 140 hospitals
OpenVistA and WorldVistA
Have all necessary fratures for a complex hospital system, including functionality for EHRS, financials, laboratories, radiologym pharmacies, and other population health
OpenVistA and WorldVistA
Used mostly in the United States, they have also been implemented in Egypt, Finland, Germany, and Mexico
OpenVistA and WorldVistA
Is one of the only open source EHRs certified by the Office of the National Coordinator (ONC) of the US Department of Health and Human Services
OpenEMR
Downloaded more than 7,000 times per month and has functionality for a patient portal, patient scheduling, EHRs, billing, and reports
OpenEMR
Has certified vendors in 13 countries including Argentina, the United Kingdom, and the United States
OpenEMR
An application which enables design of customized medical records system with no programming knowledge (although medical and systems analysis knowledge is required)
OpenMRS
A community of people working to apply health information technologies to solve problems, primarily in resource-poor environments
OpenMRS
Most popular open source electronic health records and medical practice management solution
Open EMR
superior alternative to its proprietary counterparts. With passionate volunteers and contributors dedicated to guarding OpenEMR’s status as a free, open source software solution for medical practices with a commitment to openness, kindness and cooperation
Open EMR
Main feature includes appointment scheduling e- prescribing, compliance, tracking, charting, voice recognition, billing and patient portal
Open EMR
