CHAPTER

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12Electronic Health

Records

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12-2

Learning Outcomes (cont.)

12.1 List four medical mistakes that will be greatly decreased through the use of EHR.

12.2 Differentiate among electronic medical records, electronic health records, and personal health records

12.3 Contrast the advantages and disadvantages of electronic health records

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12-3

Learning Outcomes (cont.)

12.4 Illustrate the steps in creating a new patient record and correcting an existing record

using EHR software.

12.5 Describe some of the capabilities of EHR software programs.

12.6 Explain how you might alleviate a patient’s security fears surrounding the use of EHR.

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12-4

Introduction

• Electronic health records

– Eliminates duplication forms

– Simply review information

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12-5

A Brief History of Electronic Medical Records

• Paper records becoming inadequate

• Medical errors due to – Lost or misfiled records

– Mishandled patient messages

– Inaccurate and illegible documents

– Mislabeled or illegible lab or medication orders

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12-6

Apply Your Knowledge

ANSWER: They are:Lost or misfiled records

Mishandled patient messages

Inaccurate and illegible documents

Mislabeled or illegible lab or medication order

What are the four errors that stem from communication problems?

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12-7

Electronic Records

• Electronic medical record (EMR)

• Electronic health record (EHR)– Continuity of care – Reduction in errors– Decreased costs

• Personal health record (PHR)

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12-8

Apply Your Knowledge

• Match the following:

PHI that is collected an maintained by the patient

conforms to national interoperability standards

not a legal record

used by a single healthcare organization

covered by HIPAA

ANSWER:

EHR

PHR

EMREHR

All three

EMR

PHR

PHR

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12-9

Advantages and Disadvantages of EHR

Government mandate steps1. Use all major functions of EHR

2. Use EHR to send and receive clinical information

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12-10

Advantages and Disadvantages of EHR (cont.)

3. Clinical decisions support (in development)• High priority conditions• Enrolling patients in PHR• Accessing comprehensive data• Improving population health

• E prescribing

• Incentives

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12-11

Disadvantages of EHR Programs

• Disadvantages

– Costly

– Staff training requirement

– IT staff may be needed

– Possible damage to system and software and or required upgrades

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12-12

Advantages of EHR Programs

• Fewer lost medical records

• Eliminated transcription costs

• Increased readability/legibility

• Ease of chart access for multiple users

• Chart availability outside of office hours

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12-13

Advantages of EHR Programs (cont.)

• Increased access to patient education materials

• Decreased duplication of test orders

• More efficient transfer of records

• More efficient billing processes

• Greatly decreased storage needs

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12-14

Advantages of EHR Programs (cont.)

• Accessed from other locations– Physician’s home– Satellite offices

• Used in teleconferences

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12-15

Apply Your Knowledge

What is the main reason medical practices are not implementing EHRs?

ANSWER: Cost

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12-16

Working With an Electronic Health Record

• Basic rules unchanged

• Creating a New Patient Record

• Correcting an EHR

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12-17

Working With an EHR (cont.)

• Be familiar with the hardware and software

• Keep password secure

• Check entries carefully before saving

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12-18

Apply Your Knowledge

Which statements are true and which are false?

____ All EHR programs will be the same.

___ The basic rules for working with an EHR are the same as for a paper record

____ Once you make a mistake in an EHR, there is nothing you can do to correct it.

ANSWER:

F

T

F

Although programs must communicate with each other, they may not be the same.

You can make an addendum with the correct information.

Right!

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12-19

Other Functions of EHR Programs

• Tickler files

• Specialty specific – Customized – Templates

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12-20

Other Functions of EHR Programs (cont.)

• Electronic schedulers

– Advantages

– Disadvantage

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12-21

Other Functions of EHR Programs (cont.)

• Eligibility verification and referral management

• Billing and coding

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12-22

Other Functions of EHR Programs (cont.)

• Report generators

• Electronic prescriptions

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12-23

Other Functions of EHR Programs (cont.)

• Ancillary order integration

• Patient access

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12-24

Apply Your KnowledgeMatch the following: ANSWER:

Impressive!

1. Tickler file

2. Electronic scheduler

3. Eligibility verification

4. Billing and coding

5. Report generator

6. Prescription writer

7. Ancillary order integration

8. Patient access

flags allergies

checks insurance coverage

sends an alert for follow-up care

may send a reminder to the patient

allow for electronic claims to insurance companies

office statistics

make an appointment or pay a bill

submits orders to the lab

1

2

3

4

5

6

7

8

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12-25

Security and Confidentiality and EHR

• Access code– Limits access– Date and time stamp

• Release of information policy

• Backup

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12-26

Reassuring Others about EHR Security and Confidentiality

• Know the confidentiality and security features

• No negativity

• Pamphlet explaining EHR

• Show the patient his/her record

• Explain access to patient

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12-27

Apply Your Knowledge

ANSWER: Access codes can be set to limit a person’s access to a medical record based on his/her job description. They also enable a medical practice to track who has accessed a medical record as well as when they accessed it.

What does the use of access codes enable medical practice do?

Right!

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12-28

In Summary

12.1 Medical mistakes that will be greatly decreased or eliminated with EHR include:

– lost or misfiled paper records

– mishandled or “forgotten” patient messages

– inaccurate or unreadable information in a paper medical record

– mislabeled or unreadable laboratory or prescription orders.

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12-29

In Summary (cont.)

12.2 The electronic medical record is an electronic record of health-related information for an individual patient.

An electronic health record is created, managed, and gathered in a manner that conforms to nationally recognized interoperability standards.

A personal health record is an electronic version of the comprehensive medical history and record of a patient’s lifelong health that is collected and maintained by the individual patient.

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12-30

In Summary (cont.)

12.3 Advantages of EHR include: (not inclusive)

– Fewer lost records

– No transcription costs

– Readability/legibility

– Access for multiple users

– Chart availability

– Decreased duplication of tests

Disadvantages include:

– Cost

– Need for training

– Possible need for F/T or P/T IT personnel

– Need for computer hardware/software upgrades or changes

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12-31

In Summary (cont.)

12.4 The same rules apply with EHR as for paper-based medical records when initiating or documenting in a patient’s electronic health record.

Follow the basic steps in Procedure 12-1 for setting up a new patient EHR and 12-2 for correcting or making an addition in an

existing patient’s electronic health record.

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12-32

In Summary (cont.)

12.5 Aside from housing patient electronic health records, many EHR programs also can perform the following functions: tickler files, specialty-specific software, electronic scheduler, eligibility verification and referral management, billing and coding capabilities, report generation, electronic prescriptions and ancillary order integration, and a patient access portal.

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12-33

In Summary (cont.)

12.6 Be knowledgeable of the office EHR program and never display a negative attitude about it.

Assist in preparing written information for the patients regarding the EHR program.

Show the patient his EHR, and explain how the information is entered, maintained, and kept secure.

Understand and be able to explain the backup process for the EHR program.

Understand the office access policy as it pertains to HIPAA and explain it to the patients.

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12-34

The over-all point is that new technology will not necessarily replace old technology, but it will date it. By definition. Eventually, it will replace it.

~ Steve Jobs

End of Chapter 12