HI 205 Chapter5.4ed rev6 6-18

1. Chapter 5
Electronic
Health Records

2. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 2
Overview of computer terms
• Hardware
– Central processing unit
– Input and output devices
– Storage devices
– Networking equipment
• Software
– Operating software
– Application software

3. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 3
Evolution of Electronic
Health Records
Terms used to describe automated records
• Computerized medical record
• Computer-based patient record
• Electronic medical record (EMR)
• Electronic health record (EHR)
(Continues)

4. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 4
Evolution of Electronic
Health Records (Continued 1)
• IOM’s 1991 report indicated that electronic
records should support the following:
– Physician access to patient information
– New and past test results in multiple-care settings
– Computerized order entry
– Computerized decision-support systems to prevent
adverse drug interactions and improve compliance with
best practices
– Secure electronic communication among providers/patients
(Continues)

5. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 5
Evolution of Electronic
Health Records (Continued 2)
– Patient access to records, disease management tools, and
health information resources
– Computerized administration processes such as
scheduling systems
– Standards-based electronic data storage
– Reporting for patient safety and disease surveillance efforts

6. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 6
Longitudinal Patient Record
Contains records from different episodes of care,
providers, and facilities that are linked to form a
view, over time, of a patient’s health care
encounters

7. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 7
Advantages of Manual Records
• Low start-up costs
• Training of staff is simple
• Requires less technically trained staff
• Paper records are available because there
is no downtime

8. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 8
Disadvantages of Manual Records
• Retrieval is not easily customized
• Hand-written information can be difficult
to read
• Difficult to abstract information
• Undocumented services are not easily
discovered until discharge analysis occurs

9. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 9
Advantages of Automated Records
• Improved access to patient information
• Multiple users can access patient information
simultaneously and remotely
• Elimination of paper record storage
• Improved readability of patient information
• Timely capture of data
(Continues)

10. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 10
Advantages of Automated
Records (Continued)
• Views can be customized
• Updates occur easily
• Customized retrieval of information
• Enhanced security of patient information
• Reduction in administrative costs

11. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 11
Disadvantages of
Automated Records
• Increased start-up costs
• Selection and development is time-consuming
• Staff training is time-consuming
• Staff training can be costly
• Technical staff is needed
• User resistance can occur

12. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 12
Transition to Electronic Records
• Scanning of documents
• Hybrid records
• Record transitional template

13. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 13
Regional Health Information
Organization (RHIO)
Electronic network of patient medical
information gathered from multiple
health care organizations in a geographic
region

14. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 14
Stakeholders in a RHIO
• Hospitals
• Physicians
• Patients
• Health plans and insurers
• Public/governmental health agencies

15. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 15
American Recovery
Reinvestment Act of 2009
Areas that the act will impact include
• Incentives for adoption of EHRs
• Advancement of health information exchange
• New privacy regulations
• HIM workforce opportunities

16. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 16
Components of Electronic
Health Records
• Data is defined as raw facts that are not
interpreted or processed
• Health information is defined as health data
that has been given meaning and has been
processed or organized in a manner that is
useful for decision making
(Continues)

17. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 17
Components of Electronic
Health Records (Continued)
• Characters
• Fields
• Records
• Files
• Data
• Information

18. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 18
Patient Registration Screen

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accessible website, in whole or in part. 19
Administrative &
Clinical Applications
• Registration-admission-discharge-transfer system
(RADT)
• Clinical applications
– Patient monitoring systems
– Pharmacy
– Laboratory
– Radiology
– Nursing
– Medical documentation
– Patient access

20. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 20
Patient Registration Insurance
Information

21. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 21
Clinical Information
Patient History

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accessible website, in whole or in part. 22
Patient Intake Screen at Exam

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accessible website, in whole or in part. 23
Transitioning to
Electronic Records
• Many challenges will have to be met
• Health information professionals must have
an understanding of automated systems
• Transitions to EHRs can take years
• Facilities need to establish and develop
implementation plans

24. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 24
Beyond Health Data and Health
Information
• Health Information Exchanges- Allows for
shared patient information.
• Patient information must be managed.
• Patient data and information is used for patient
care and throughout the health care industry.
(Continues)

25. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 25
Beyond Health Data and Health
Information (Continued)
• Data Governance: creation of policies,
processes, and procedures that focus on the
management of data and information that
relates to patient care and the operations of the
health care organization.
• Information Governance: creation of
organization-wide policies, principles, and
practices that focus on the management of
information that is produced by the various
systems within the health care organization.

26. © 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part. 26
AHIMA’s Information Governance
Principles for Healthcare
• Accountability
• Transparency
• Integrity
• Protection
• Compliance
• Availability
• Retention
• Disposition

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accessible website, in whole or in part. 27
Health Information Professionals
Role
What will the role of the Health Information
Professional be as health care facilities automate
patient records and expand patient information
systems?