Medical assisting Administrative and clinical procedures (5e) Chapter 12 Electronic health records

After studying this chapter you will be able to: List four medical mistakes that will be greatly decreased through the use of EHR; differentiate among electronic medical records, electronic health records, and personal health records; contrast the advantages and disadvantages of electronic health records;...

Electronic Health

Records

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

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

• Electronic health records

– Eliminates duplication forms

– Simply review information

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

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?

Electronic Records

• Electronic medical record (EMR)

• Electronic health record (EHR)

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

Advantages and Disadvantages of EHR

Government mandate steps

1 Use all major functions of EHR

2 Use EHR to send and receive clinical

information

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

Disadvantages of EHR Programs

• Disadvantages

– Costly

– Staff training requirement

– IT staff may be needed

– Possible damage to system and software and

or required upgrades

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

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

Advantages of EHR Programs (cont.)

• Accessed from other locations

– Physician’s home

– Satellite offices

• Used in teleconferences

Apply Your Knowledge

What is the main reason medical practices are

not implementing EHRs?

ANSWER: Cost

Working With an Electronic Health Record

• Basic rules unchanged

• Creating a New Patient Record

• Correcting an EHR

Working With an EHR (cont.)

• Be familiar with the hardware and software

• Keep password secure

• Check entries carefully before saving

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

You can make an addendum with the correct information.

Right!

Other Functions of EHR Programs

• Tickler files

• Specialty specific

– Customized

– Templates

Other Functions of EHR Programs (cont.)

• Electronic schedulers

– Advantages

– Disadvantage

Other Functions of EHR Programs (cont.)

• Eligibility verification and referral management

• Billing and coding

Other Functions of EHR Programs (cont.)

• Report generators

• Electronic prescriptions

Other Functions of EHR Programs (cont.)

• Ancillary order integration

• Patient access

Apply Your Knowledge

Match the following: ANSWER:

office statistics make an appointment or pay a bill submits orders to the lab

1 2 3

4 5 6

7 8

Security and Confidentiality and EHR

• Access code

– Limits access

– Date and time stamp

• Release of information policy

• Backup

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

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!

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.

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.

– 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

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

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

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.

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