terminology in health care and public health settings unit 15 overview / introduction to the ehr
TRANSCRIPT
Terminology in Health Care and Public Health
Settings Unit 15
Overview / Introduction to the EHR
Last Next Ten Years
• Improved Technology• Government Support• Receptivity of Healthcare Professionals• Receptivity of Patients
= Use of Electronic Records
= Amount of Data
Health IT Workforce Curriculum Version 1.0/Fall 2010
2Component 3/Unit 15a
Health IT Workforce Curriculum Version 1.0/Fall 2010
3Component 3/Unit 15a
The Electronic Health Record
• Common acronyms for electronic records for patient data– EHR: electronic health record (across the
lifespan)– CBMR: computer based medical record– CPR: computerized patient record– EMR: electronic medical record– EPR: electronic patient record– PHR: personal health record
Health IT Workforce Curriculum Version 1.0/Fall 2010
4Component 3/Unit 15a
Functions of the Health Record
• Document patient care• Provide communication among healthcare team
members• Financial and legal record• Research and continuous quality improvement• Repository of the clinical thought processes
recording ideas and impressions over the period of care
• Single point at which all clinical data are archived for long-term use
Health IT Workforce Curriculum Version 1.0/Fall 2010
5Component 3/Unit 15a
Attributes of the EHR
• Enormous capabilities of data storage in a small space
• Accessible from remote sites to multiple people at the same time
• Information retrieval can be almost instantaneous• Provide clinical alerts, expert systems, and reminders
Health IT Workforce Curriculum Version 1.0/Fall 2010
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Attributes of the EHR
• Can link the clinician to protocols
• Create customized views
• Improve risk management
• Provide outcomes assessment
• More accurate capture of financial charges and billing efficiency
• Increases patient satisfaction
Health IT Workforce Curriculum Version 1.0/Fall 2010
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Health IT Workforce Curriculum Version 1.0/Fall 2010
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Data rich and information poor?
Component 3/Unit 15a
Rights of Information
Right information: must be accurate, free from error, and meaningful
Right person: communicated to the person who will respond to them
Right time: crucial to the health of an individual, give to the decision-maker within a few minutes or hours
Right place: must be accessible at the point of care Right amount: decisions can be made faster when
only the information desired is available
Health IT Workforce Curriculum Version 1.0/Fall 2010
9Component 3/Unit 15a
American Recovery and Reinvestment Act (ARRA)
• $19B for HITECH –Health Information Technology for Economic and Clinical Health
• Center for Medicaid and Medicare Services (CMS)– Incentive Payment, Meaningful Use
• Office of the National Coordinator for Health Information Technology (ONC)– Certification Standards
Health IT Workforce Curriculum Version 1.0/Fall 2010
10Component 3/Unit 15a
Meaningful Use
“The effective use of information to support better decision-making and more effective care processes that improve health outcomes and reduce cost growth”
1.Data Capture and Sharing2.Advanced Clinical Processes3.Improved Outcomes
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The Markel Foundation: Connecting for Health, “Achieving the Health IT Objectives of the American Recovery and Reinvestment Act” April 2009
Component 3/Unit 15a
Data Capture and Sharing
• Improve Quality, Safety and Efficiency• Engage Patients and Families• Improve Care Coordination• Improve Population and Public Health• Ensure Privacy and Security Protections
Health IT Workforce Curriculum Version 1.0/Fall 2010
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Improve Quality
• Use CPOE• Formulary Checks• Problem List• e‐Prescribe• Rx List• Rx Allergy List• Record Demographics• Record physiological data• Growth charts for children
between 2 and 20
• Record Smoking (> 13 Yrs)
• Structured Lab Results
• List Patient by Condition
• Report Quality Measures
• Patient Reminders (50 Yrs or >)
• Clinical Decision Support ("Relevant to Clin Quality Measures“)
• Check Eligibility
• Submit Electronic Claims
Health IT Workforce Curriculum Version 1.0/Fall 2010
13Component 3/Unit 15a
Engage Patients and Families
• Patient e‐Access on Request (Including Discharge Summary/ Instructions from hospital)
• Patient e‐Access to Record (Patient Portal)
• Clinical Summaries each Visit (Portal, email, CD, USB, Paper)
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Improve Care Coordination
• Exchange Health Info with other Provider
• Medication Reconciliation
• Summary Care Record for each Transition/Referral: Transfers w/Summary
Health IT Workforce Curriculum Version 1.0/Fall 2010
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• e‐Submit to Immunization Registries (Hospital also submits to Department of Public Health)
• Syndromic Surveillance to Department of Public Health
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Improve Population and Public Health
Final Revisions to the ARRA Meaningful Use Rule
• Final revisions to the rule July 13, 2010
• http://www.ofr.gov/OFRUpload/OFRData/2010-17210_PI.pdf
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Summary of Objectives
The “Meaningful Use” Regulation for Electronic Health Records. NEJM, July 13th, 2010
http://healthcarereform.nejm.org/?p=3732
Health IT Workforce Curriculum Version 1.0/Fall 2010 18Component 3/Unit 15a