An Introduction to Electronic Health Records

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CONFIRMING PAGES,2 Chapter One,LO 1 1 THE ELECTRONIC HEALTH RECORD HISTORY. The concept of a patient s medical information stored electronically instead of. Focal Point on paper is not a new one In the 1960s as medical care became more complex. Improvement to the quality doctors realized that in certain situations the patient s complete health history. of patient medical care would not be accessible to them The availability of comprehensive medical. and safety has always information when needed brought the innovation of storing the patient s in. been the catalyst for formation electronically Improvement of patient medical care was and is the. the development of the,catalyst for the electronic health record EHR. electronic health record, The Mayo Clinic in Rochester Minnesota and the Medical Center Hospital. of Vermont were some of the first clinics to utilize an electronic medical record. system Their systems were developed in the early 1960s Over the next two de. cades more information and functionalities were added to the electronic medical. Electronic Health record system in order to improve patient care Drug dosages side effects aller. Record EHR gies and drug interactions became available electronically to doctors enabling. Electronic health records that information to be incorporated into electronic health care systems Electronic. is the most commonly diagnostic and treatment plans which gave doctors information for patient care. accepted term for proliferated and were integrated into electronic medical record systems More. software with a full range academic and research institutes developed their own computerized medical. of functionalities to store record systems as tools to track patient treatment Overall the utilization and. access and use patient medi growth of these computer models was to increase the quality of patient care. cal information,LO 1 2 METHODS OF DATA ENTRY, As computer technology continues to rapidly develop the versatility of the. EHR becomes greater Access through the EHR to patient information medi. cal alerts warnings drug information and disease management is now at the. Point of Care point of care for the health care provider in a more user friendly form Modes. Point of care is the time and of data entry into the EHR have progressed Traditionally a keyboard was the. place of care being given to only source for data entry However the need for convenience efficiency and. the patient from the health speed has mandated other methods Voice recognition systems adapt to a per. care provider son s voice and speech patterns so that the computer inputs data as the opera. tor speaks Electronic handwriting recognition is also now available These two. methods of data input are not commonly used because they require that the. user repeat the same activity each time the data is needed More commonly. large bodies of preset text known as templates can be easily selected to input. into the patient s record Instead of significant amounts of typing health care. providers can enter data and access data through a few taps of a stylus pen on a. touch screen or the click of a mouse Touch screens are utilized on such devices. Tablet PC as a Notebook Tablet or a Tablet PC making the EHR portable and accessible for. A portable handheld easy data entry The ease of use and speed of the Tap Go feature with the. computer with the ability to Tablet PC has made EHRs more desirable Traditionally a stationary computer. document directly on the workstation in each exam room has been cost prohibitive for the independent. screen with a stylus pen physician or a desktop computer may not be available at the point of care. resulting in delayed data entry thus patient information is not readily avail. able to other physicians and medical support staff However in recent years. the increased use of laptops Tablet PCs and wireless connectivity has brought. greater mobility and lower costs to the health care provider. Local Area Network Networks have advanced in security and reliability to enable both flexibil. LAN ity and mobility of the EHR A Local Area Network LAN enables comput. A wired and or wireless ers to communicate together and utilize a main server for the database The. connection of computers on LAN system is very customizable according to the office needs This network. a single campus or facility system may consist of wired connections and or utilize a wireless network as. Copyright 2011 by The McGraw Hill Companies Inc,ham74393 ch01 001 015 indd 2 12 9 09 1 18 43 PM.
CONFIRMING PAGES,An Introduction to Electronic Health Records 3. Internet via DSL cable or,other broadband connection. Focal Point,The affordability of both,PC 1 PC 2 Laptop Tablet PC. hardware and software, Figure 1 1 Hardwired and wireless LAN system and the reliability of. intranet technology and,wireless connectivity, illustrated in Figure 1 1 The wireless LAN networks enable health care provid have enabled many.
ers full or open access to their EHRs from anywhere within their office independent physicians to. Internet and intranet technologies have increased the availability of medical take advantage of the EHR. databases that can be shared and accessed across large distances This remote in recent years. access gives health care providers entrance to their EHR from such remote loca. tions as nursing homes a home office or hospitals through an Internet con. nection These networks are secure and access is limited Data flowing on the. network is also encrypted for security Intranet Technologies. Another network option for a medical practice is the web based EHR or Intranet technology is a pri. Application Server Provider ASP The EHR is accessed by the health care vately maintained computer. provider via the Internet In this model the medical practice does not house the network that provides secure. software on a computer server at the medical office Maintenance updates and accessibility to authorized. backups are conducted remotely by the EHR web hosting company High speed persons especially members. or employees of an organiza,tion enabling the sharing of. software database,CC and les,Concept Checkup 1 1 LO 1 1 LO 1 2. A Encrypted, was the initial reason and continues to be the reason for the When computer data is. development of electronic health records EHRs changed from its original. form to be transmitted, B Several modes of data entry into the EHR programs exist Some of securely so as to be unintelli. these methods of data entry are gible to unauthorized parties. and then decrypted back,into its original form for use.
Application Server,3 Provider ASP,This enables a doctor s o ce. to access an EHR via the, C What two types of technologies have increased the availability of Internet whereas the EHR. medical databases and access to the EHR software and database are. housed and maintained by,a separate company in a,2 remote location. Copyright 2011 by The McGraw Hill Companies Inc,ham74393 ch01 001 015 indd 3 12 9 09 11 49 16 PM. CONFIRMING PAGES,4 Chapter One, Internet connectivity is required in this situation However concerns can be the.
security of the EHR the speed of downloading and uploading images or large. files and ensuring that the Internet connectivity is always available 1. LO 1 3 ACRONYM ALPHABET SOUP, An alphabet soup of acronyms surrounds electronic health records EHRs. Some of these definitions have been flexible and reveal an evolution of terms. and meanings to government agencies and independent associations influenc. ing the field of electronic health records The differences are not just semantics. the terms have evolved with more and more distinct definitions They disclose. some of the history in the progression of the electronic health record However. although the following terms and meanings are supplied to help with clarity. the various acronyms can all still be used to describe the concept of an electronic. health record, EHR Electronic Health Record Currently this term is the most com. monly accepted and used term for storing and accessing patient medical. information electronically EHR encompasses a full range of functionalities. and information including patient demographics progress notes problems. medications vital signs past medical history immunizations laboratory. data radiology reports scheduling transcription e prescribing evaluation. and management office visit level coding care alerts chief complaints. evidence based decision support and health maintenance In the future an. EHR will include a continuity of care record CCR and the personal health. record PHR standards for these functionalities are still being developed. Electronic Medical EMR Electronic Medical Record This term was widely used as the terms. Record EMR migrated away from the computer based patient record As definition of. The term for software that terms became clearer EMR came in second to the fully functional EHR An. lacks a full range of higher EMR does not offer certain high end functionalities such as health main. end functionalities to store tenance and disease management care alerts the CCR continuity of care. access and use patient medi record personal health record functions or interconnectivity with provid. cal information ers outside the practice, CPR Computer Based Patient Record This term was one of the first used to. Interoperability conceptualize the idea of an EHR A computerized patient record is a lifetime. Interoperability is the abil patient record that includes all information from all specialties even dentistry. ity of a software program to and psychiatry and is available to all providers potentially internationally. accept send or communi Because the CPR requires full interoperability between EHRs the CPR is not. cate data from its database realistic in the foreseeable future In the early 1990s there was an initiative to. to other software programs, use the CPR however the concept evolved into the EMR and EHR. from multiple vendors, EPR Electronic Patient Record EPR is similar to the CPR but does not.
Continuity of Care necessarily contain a patient s lifetime record and does not include dental. Record CCR behavioral or alternative care It focuses on the patient s relevant medical. A core set of provider information, oriented health data re ect CCR Continuity of Care Record The CCR is health provider oriented. ing the most relevant and and defines a core set of data reflecting the most relevant and timely facts. timely facts about a patient s about a patient s health care The CCR would be a subset of the EHR Typi. health care It is vendor and cally it includes patient information diagnoses recent procedures allergies. technology neutral enabling medications and future treatment plans It should be accessible to all care. the access of patient infor providers whenever needed The electronic CCR is designed to be vendor. mation between health care and technology neutral that is accessible and readable by other electronic. providers systems The CCR should be updated by the practitioner at the close of a. Copyright 2011 by The McGraw Hill Companies Inc,ham74393 ch01 001 015 indd 4 12 9 09 1 18 43 PM. CONFIRMING PAGES,An Introduction to Electronic Health Records 5. patient encounter or upon the transfer of data from one caregiver to another. whether inpatient outpatient or community based, PHR Personal Health Record The PHR allows the patient to become an Personal Health Record. interactive source of health information and health management through PHR. an Internet based connection to the practice website Through a secure con PHRs allow the patient. nection patients may schedule appointments request medication refills access via the Internet. access lab or radiology results and ask questions about their health Some to store and update per. PHRs enable patients to complete or update family or social histories or sonal medical information. even read their medical records and notify providers of incorrect or missing and make inquires to the. information patient s health care provider,about prescriptions appoint.
ments or concerns,Concept Checkup 1 2 LO 1 3, A What is most commonly accepted term for storing and accessing. patient medical information electronically, B What term was one of the rst used to conceptualize the idea of an. electronic health record EHR,LO 1 4 BARRIERS TO THE EHR. Although Electronic Health Records EHRs bring tremendous benefits to pa. tient care and to the health care provider use of the ambulatory EHR instead Ambulatory. of the paper chart did not become widespread among the independent physi The capability of walking or. cians during the 1990s Even though the motivation of improved patient care the ability to move from one. and availability of medical data was present health care providers were hesi place to another In a medi. tant to begin using this medical tool Specific reasons have been hypothesized cal sense it is used to distin. for the lack of EHR implementation and they are outlined below guish walking patients from. patients who are bedridden,as in an inpatient hospital or. A Lack of Standards for EHR Systems,skilled nursing facility.
The content within the systems did not have uniformity for compatibility or. interoperability Various programs offered different features and the exchange. of data was not possible Also standards for the security of confidential infor. Explain a brief history of Electronic Health Records EHRs user repeat the same activity each time the data is needed More commonly large bodies of preset text known as templates can be easily selected to input into the patient s record Instead of signifi cant amounts of typing health care providers can enter data and access data through a few taps of a stylus pen on a touch

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