Lecture Electronic health records for allied health careers: Chapter 2 - Susan Sanderson

Chapter 2 - Transitioning to an electronic health record and the need for clinical information standards. After studying this chapter, you should be able to: Describe the major strategies for converting paper-based charts to HER; list the four ways of entering live patient data into HER; explain how desktop, laptop, and tablet computers differ;...

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Chapter 2

Transitioning to an Electronic Health Record and the Need for Clinical Information

Standards

Records for Allied Health Careers

Learning Outcomes

After studying this chapter, you should be able to:

Describe the major strategies for converting paper-based

charts to EHR

List the four ways of entering live patient data into EHR

Explain how desktop, laptop, and tablet computers differ

Discuss the advantages of wireless networks in health care Explain the major difference between locally hosted and ASP

hosting models

Learning Outcomes

After studying this chapter, you should be able to:

Discuss why the adoption of clinical standards is critical to

the successful implementation of electronic health

records

Describe the difference between clinical vocabularies and

classification systems

List four messaging standards used with electronic health

records

Describe the significance of the Medicare Prescription Drug

and Modernization Act of 2003 in the adoption of clinical standards

Key Terms

application service provider (ASP)

classification systems

clients

clinical templates

clinical vocabularies

Current Procedural Terminology

(CPT)

content standards

desktop computer

Digital Imaging and

Communications in Medicine

(DICOM)

Healthcare Common Procedures

Coding System (HCPCS), Level

II

Health Level Seven (HL&) hybrid conversions

incremental conversion Institute of Electrical and Electronics Engineers 1073 (IEEE1073)

International Classification of Diseases, Ninth Revision interoperable

laptop computer locally hosted Logical Observation Identifiers Names and Codes (LOINC) messaging standards

Key Terms

National Council for Prescription

Drug Program (NCPDP)

network

outsourcing

personal digital assistant (PDA)

picture archiving and

communication system (PACS)

scanning

server

smart phones

Systematized Nomenclature of Medicine Clinical Terms

(SNOMED-CT) tablet computer total conversion Unified Medical Language System (UMLS)

voice recognition wired network wireless networks workstations

Converting Existing Records

Conversion strategies:

Total conversion

Incremental conversion

Hybrid conversion

Entering Live Data

Methods:

dictation and transcription

clinical templates

voice recognition

scanning

Computer Requirements

Input Devices

Workstations

– desktop computers

– laptop computers

– tablet computers

– personal digital assistants (PDAs)

– smart phones

Computer Requirements

Networks

– server = “hub” of network; houses data and

applications

– clients = computers that access the server over the

network

– wired network vs wireless network

Hosting Choices

Locally Hosted Model

Application Service Provider Model

Blended or Hybrid Model

The Importance of Clinical Standards

For shared information to be useful, computer

systems must be interoperable

No mandatory standards for clinical data exist

yet.

Clinical Information Standards

Clinical vocabularies

– Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT)

– Logical Observation Identifiers Names and Codes

(LOINC)

– U.S National Library of Medicine Unified Medical

Language System (UMLS)

Clinical Information Standards

Classification systems

– International Classification of Diseases, Ninth Revision (ICD-9)

– International Classification of Diseases, Tenth Revision (ICD-10)

– Current Procedural Terminology (CPT)

– Healthcare Common Procedures Coding System

(HCPCS), Level II

Clinical Information Standards

Messaging Standards

– Health Level Seven (HL7)

– Digital Imaging and Communications in Medicine

(DICOM)

– Picture Archiving and Communication System (PACS)

– National Council for Prescription Drug Program

(NCPDP)

– The Institute of Electrical and Electronics Engineers

1073 (IEEE1073)

Clinical Information Standards

EHR Content Standards

– Electronic Health Record System Functional Model

(EHR-S-FM)