Chapter 2 Electronic Health Records



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Chapter 2

Electronic Health Records

What is Health Informatics

  • EHRs are also known as electronic medical records (EMRs), computerized medical records (CMRs), electronic clinical information systems (ECIS) and computerized patient records (CPRs).

What is an Electronic Health Record

  • An Electronic Health Record is computer software used to capture, store, and share patient data in a structured way.
  • An EHR is able to share medical information among all the authorized parties involved in the patient’s care: clinicians, labs, pharmacies, emergency facilities, nursing homes, state registries, and patients themselves.

What is an Electronic Health Record

  • EHR systems replace traditional paper-based medical records, allowing healthcare providers to access and share patient information quickly and securely across different healthcare settings, such as hospitals, clinics, and laboratories.

EHR Workflow

  • EHR exists to support the workflow already present in the clinic. It also implies the connectivity between all members of the patient care environment. 

Need for Electronic Health Records

  • Paper Records Are Severely Limited
  • for Improved Efficiency and Productivity
  • Quality of Care and Patient Safety
  • Governmental Expectations
  • Public Expectations
  • Financial Savings
  • Technological Advances
  • for Aggregated Data
  • for Integrated Data

The following are features found in most current EHRs:

  • Clinical decision support systems (CDSS) to include alerts, reminders and clinical practice guidelines.
  • Secure messaging (e-mail) for communication between patients and office staff and among office staff.
  • Referral management feature
  • Retrieval of lab and x-ray reports electronically
  • Retrieval of prior encounters and medication history
  • Computerized Physician Order Entry.
  • Electronic patient encounter.
  • The ability to input or access information via a smartphone or tablet PC.
  • Remote access from the office, hospital or home

The following are features found in most current EHRs:

  • Electronic prescribing
  • Public health reporting and tracking
  • Ability to generate quality reports
  • Ability to scan in text or use optical character recognition (OCR)
  • Ability to perform evaluation and management (E & M) determination for billing
  • Robust backup system

Clinical and Administrative Workflow in a Medical Office

  • Several steps are common to almost any medical practice with regards to treating patients and getting reimbursed properly for the services provided.

Information management in electronic environment

  • Health information management (HIM) traditionally focused on the paper medical record and coding.
  • With the advent of the electronic health record HIM specialists now have to deal with a new set of issues, such as privacy and multiple new concepts such as voice recognition.

Challenges of Implementing EHR Systems

  • Data Quality
  • Integration with existing systems
  • User Adoption
  • Security

Conclusion

  • Electronic health records are central to creating health information organizations and a nationwide health information network

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