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Unit-IV EMR II sem 2022.pptx

  2. Model of EHR/EMR
  3. Syllabus learning outcomes  Unit-iv  Total hours theory : 04 hrs  Total practical hours : 04 hrs  To explain the use of electronic health records in nursing practices  To describe the latest trends in electronic health records standards and interoperability
  4. Teaching and learning activities  Lecture method  Discussion method  Practice on simulated EHS system  Practical session  Visit to health informatics department of a hospital to understand the use of EHR in nursing practice
  5. Abbreviation  EHR-Electronic Health Record  EMR-Electronic Medical Record  PHR-patient Health Record  NHIN-National Health Information Network  CPR-computer Based Patient Record  HITECH-Health Information Technology For Economic and Clinical health Act  MIPPA-Medicare Improvement for patient and provider Act
  6. Continued  HIE-health Information Exchanges  HIT-Health Information Technology  PMS-Practice of management System  PDA-personal Digital Assistant  ROI-Return Of Investment  ARRA-American Recovery and Reinvestment Act  CMS-Centre for Medicare and Medicaid services  PACS- Picture Archiving and communication System  HIPPA- Health Insurance Portability and Accountability Act
  7. Terminology  EHR: An electronic (digital) collection of medical information about a person that is stored on a computer.  EMR: An Electronic Medical Records (EMR) Nurse uses modern technology to manage and organize patient health information.
  8. Terminology  Health :Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity“  Records: A record is a permanent written communication that documents information relevant to a client's health care management, e.g. a client chart is a continuing account of client's health care status and need.  Electronic :
  9. Terminology  SOAP- notes should include Subjective, Objective, Assessment, and Plan  An electronic health record (EHR) is a digital version of a patient’s paper chart.  EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care.
  10. Continued  HIPPA-Health Insurance Portability and Accountability Act.1996 (Insurance: Medical insurance) In the U.S., HIPAA is an act that protects people covered by health insurance and makes rules about storing personal medical data.
  11. Learning objectives  To introduce the topic  To list the abbreviation used in topic  To describe the terminology used in topic  To define the EHR and EMR  To enlist the purpose of EMR/EHR  To enlist the general purpose ?  To describe the core function?  To discuss the components of EHR?  To discuss the health care standard  To describe the application of EMR in hospital services  To explain the data privacy and security
  12. Definition of EMR What is EMR?  An electronic medical record (EMR) is a digital version of the patient-specific medical information that is traditionally kept in a paper "chart" or medical record Nursing informatics  Nursing informatics is “a combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care.
  13. Meaning of EMR  Electronic medical health record means health related information on an individual within one health organization .  An EHR system is a computerized, organized collection of individual patients’ healthcare information in a digital format  Functions  – Store  – Share  – Transmit electronic data
  14. History of EMR  tate of Electronic Health Records (EHRs) in 1992 and their evolution by 2015 and where EHRs are expected to be in 25 years.  September 2013  In September 2013 the Ministry of Health & Family Welfare (MoH&FW) notified the Electronic Health Record (EHR) Standards for India.
  15. Concept of EMR/EHR  EHR programs collect health information for individual patients in inpatient and outpatient settings  – Saves in a digital format  – Collects information that is typical of what you would see in paper records  – Interfaces with external healthcare computer programs  – Transmits labs, orders, prescriptions, and results electronically  – Produces comprehensive reports on diagnoses and diseases for governmental reporting
  16. What are the six main objectives of an EHR These functions include:  health information and data.  result management.  order management.  decision support.  electronic communication and connectivity.  patient support.  administrative processes and reporting.  reporting and population health.
  17. Purpose of EMR Purpose of EMR Provide the electronic equivalent of the patient chart Bring together all of the data about a patient into a single source Support patient care and improve its quality Support and enhance physician decision making  provide individual health related information in printed form
  18. GENERAL PURPOSES EMR/EHR  Nursing’s data needs fall into four domains:  Nurse need data about client care,  provider staffing, administration of care and  the organization, and  knowledge based research. The first three are distinct areas, whereas research interacts with all of the other three.
  19. The four areas and the source for the data are:  Client: client care/ clinical care and its evaluation, clinical data, and client outcomes. Source: the client record.  Provider: professional data, caregiver outcomes, and decision maker variables. Source: personnel records, national data banks, and links to client records.  Administrative: management and resource oversight, administrative data, system outcomes, and contextual variables. Source: executive/ managerial data and fiscal and regulatory data.  Research: knowledge base development. Source: existing and newly gathered data and relational data bases.
  20. 8 Core Functions of EHRs  Health information and data.  Results management.  Order entry and management.  Clinical decision support.  Electronic communication and connectivity.  Patient support.  Administrative processes.  Reporting and population health management.
  21. Most important part of EHR  Billing System Billing records are an important part of hospital profitability, productivity, and efficiency. That's why they're one of the key components of an EHR system as they can track all the charges that a patient occurs while undergoing care.
  22. Types of EHR Systems  Physician-Hosted System. Physician-hosted systems very basically mean that all data is hosted on a physician's own servers. ...  Remotely-Hosted System. Remotely-hosted systems shift the storage of data from the physician to a third party. ...  Remote Systems.
  23. 12-Point Medical Record Checklist : What Is Included in a Medical...  1.Patient Demographics: Face sheet, Registration form  2.Financial Information:  3.Consent and Authorization Forms: ...  4.Release of information: ...  5.Treatment History: ...  6.Progress Notes: ...  7.Physician's Orders and Prescriptions: ...  8.Radiology Reports:  9. Nursing Notes:  10. Medication List:  11. HIPAA Notice of Privacy Practices:  12. Patient Confidentiality:
  24. Examples of electronic health records  EHRs include information like your age, gender, ethnicity, health history, medicines, allergies, immunization status, lab test results, hospital discharge instructions, and billing information.  OPD registration  IPD registration  Progress notes  Vital monitoring  Blood transfusion  Laboratory test etc
  25. Health care standard EMR
  26. Standardized clinical Health Records
  27. Hospital base medical devices connectivity
  28. EMR application scope
  29. Out patient uses of EMR
  30. Drawing application of EMR
  31. In patient Record of EMR
  32. Patient link base health record
  33. Equipment interface and PACS
  34. Imaging interface
  35. EMR interfaces
  36. Data Privacy Protected Health Information Information that relates to patient past, present, or future, physical or mental health or condition of an individual Information regarding payment for the healthcare to an individual Information regarding the delivery of health services Information is or can be reasonably identifiable Information is transmitted or held in electronic form or any other form or medium, including paper
  37. Data security use of EMR Administrative safeguards Security management process Assigned security Responsibility Workforce security Information access management Security awareness training Security incident procedures Contingency plan Evaluation Business associate contracts & others Physical Safeguards Facility access controls Workstation use Workstation security Device and media controls Technical Safeguards Access controls Audit controls Integrity Person or entity authentication Transmission security
  38. Reviewing the outcomes EHR  One year later, the project has expanded to many avenues of nursing, including RN orientation, preceptor classes, and individual unit education.  Subsequent auditing (3, 6, and 9 months after education) shows improved documentation in areas with significant effect on patient care and safety, including these 3-month results:  admission medication reconciliation—from 52% to 70%  isolation indication—39% to 100%  plan of care appropriate for patient’s chief com- plaint— 83% to 100%
  39. Continued  plan of care related to patient co-morbidities— 30% to 87%  education level—4% to 17%  safe patient handling—4% to 13%.  discharge planning—4% to 17%.
  40. Assessment method  Essay  Short answer  Objectives  Checklist
  41. Question related topic  Define the EHR?  Define EMR?  List out the concept of EHR?  List out the main Objectives of HER?  Discuss the Core Function of HER?  Enlist the type of HER system?  Describe the components of EHR?  List out Example of HER?
  42. Fill in the Blanks  1. HIPP Act started in ----------------------  2. HER records initiated in -------------------year------  3. In ------------------ the Ministry of Health & Family Welfare (MoH&FW) notified the Electronic Health Record (EHR) Standards for India.
  43. Summary  Till now we discussed about EMR and its significance of health care services like , meaning, aim, purpose, standard, application , challenges of patient information in computer form, interfaces, data security etc.
  44. Conclusion  I hope you all understand about the electronic health records and importance in health care services. If you got chance to do application of knowledge and skill in EHR/EMR of future. Will you all able to apply this knowledge confidently without any interruption.
  45. References 1. Affordable Care Act (ACA). 2010. care-act Agency for Healthcare Research and Quality (AHRQ). Slide set: National quality strategy overview. 2017. 2. American EMRs Association (ANA). Nursing: Scope and standards of practice. Silver Spring, MD: 2010; nursing-documentation.pdf 3. Beck SL, Weiss ME, Ryan-Wenger N, et al. Measuring nurses’ impact on health care quality: Progress, challenges, and future directions. Med Care. 2013;51(4 Suppl 2):S15-22. 4. Bowman S. Impact of electronic health record systems on information integrity: Quality and safety implications. Perspect Health Inf Manag. 2013;10:1c. 5. Conn J. Joint Commission puts focus on EHR, patient safety. Modern Healthcare. July 3, 2013. 6. Gibbs G. Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Further Education Unit; 1988. 7. Hendrich A, Chow MP, Skierczynski BA, Lu Z. A 36-hospital time and motion study: How do medical-surgical nurses spend their time? Perm J. 2008;12(3):25-34. 8. Joint Commission, The. Sentinel event alert 54: Safe use of health information technology. March 31, 2015.
  46. Thank you
  47. Electronic health records (EHR)  Learning objectives :  Illustrate the steps in creating a new patient record and correcting an existing record using EHR software.  Describe some of the capabilities of EHR software programs.  Explain how you might alleviate a patient’s security fears surrounding the use of EHR.
  48. Continued
  49. EHR terminology
  50. Introduction Electronic health records  Eliminates duplication forms Simply review information  Electronic health records enable a specialist to have a patient’s information before the patient arrives at the office.  No need to fill out the patient’s medical history each time.  The specialist only has to review the information with the patient to verify that everything is correct.
  51. Definition of EHR  Electronic health record means health related information on an individual across the more than one health organization.
  52. Trends in EHR
  53. Purpose of patient record  Purpose of a Patient (medical) Record “to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions” Reiser, S. (1991).
  54. 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
  55. History of the Electronic Health Record  Purpose:  – To improve patient medical care by having information accessible for informed medical decision making Started:  – 1960s First Facilities to use EHR Systems:  – Mayo Clinic in Rochester, Minnesota  – University Hospital in Burlington, Vermont  – Latter Day Saints Hospital in Salt Lake City, Utah History of EHR
  56. Continued  Improved Functionality:  – 1960-1980s Enter Independent Medical Offices:  – 1990s  – Called practice management systems  – Designed for fiscal management  Vendors Proliferate:  – 2000s  Governmental Mandates and Funding:  – Current  – Causing acceleration of EHRs
  57. Learning Outcome:  List four medical mistakes that will be greatly decreased through the use of EHR.  In the early 1990s, it became apparent that paper medical records were inadequate.  The increasing need for coordination of care, rising healthcare costs, and the alarming increase in medical errors. Most of these errors can be traced to communication problems, including:  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
  58. Reason for Adaptation of EHR  President George W. Bush signed an executive order in August of 2006 to promote the overall efficiency and quality of healthcare in America.  These goals will help to control the rising cost of healthcare  Most Americans will have access to electronic health records by 2014.  A decrease in medical errors through record legibility and uniformity of records  An increase in information available among patients, medical providers, and the insurance carriers.  The electronic record is quickly becoming the physician’s most important business and legal record.
  59. Government Involvement in EHR system  1991 – IOM called for eliminating paper records by 2001  2004 – Bush created the ONC position and empowered HHS to promote EHRs  2008 – Obama promised to sponsor adoption of EHRs through stimulus package  2008 – Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)  2009 – Health Information Technology for Economic and Clinical Health (HITECH) Act provided $19.2 billion to accelerate use of EHRs over 5 years (part of ARRA – American Recovery and Reinvestment Act of 2009)
  60. Continued  Bonus from CMS – Participants meeting certain requirements were eligible for this bonus  Beacon Community Program – 17 communities were chosen across the US to receive grants in exchange for documenting best practices and working to establish national goals Regional  Extension Centers – Provide training and support services to assist primary healthcare providers in adopting EHRs – Offer information and guidance to help with EHR implementation and achieving meaningful use to qualify for incentive payments – Give technical assistance as needed HITECH Act
  61. Shared system of EHR
  62. Electronic Records Electronic medical record (EMR) Electronic health record (EHR)  Continuity of care  Reduction in errors  Decreased costs Personal health record (PHR) – an electronic version of the comprehensive medical history and record of a patient’s lifelong health, collected and maintained by the individual patient.
  63. EHR Models  Web based personal health care model  Distribution base model  Facility base model
  64. Type of Records Used EHR/EMR
  65. Type of EHR records Personal health record (PHR) Learning Outcome: Differentiate among electronic medical records, electronic health records, and personal health records Electronic medical record (EMR) – an electronic record of health-related information for an individual patient that is created, compiled, and managed by providers and staff members located within a single healthcare organization.
  66. Continued Electronic health record (EHR) – If that same information on an individual patient is created, managed, and gathered in a manner that conforms to nationally recognized interoperability standards. It can be utilized by members of more than one healthcare organization.  These EHRs are the federal government’s ultimate goal. Any provider with an interoperable EHR system will have access.  They will facilitate continuity of care, reduce in medical errors, and decrease healthcare costs
  67. Patient health Record Models
  68. Benefit of Electronic Health Record To Patients
  69. Advantages and disadvantages of EHR
  70. Health care process of EHR Accessibility  Paper – chart must be located, pulled, handled, and refiled  EHR – multiple providers can access at same time  Review comparison of workflow in paper vs. EHR in Data arranging
  71. Advantages and disadvages
  72. Barriers and Benefits of the EHR Barriers to the EHR  Lack of standards  Unknown costs and return on investment  Difficulties operating EHR systems  Significant changes in clinical/clerical processes  Lack of trust and safety
  73. Benefits of the EHR  Enhanced accessibility to clinical information  Improved patient safety  Enhanced quality of patient care  Greater efficiency and savings
  74. Future of EHR  EHR is here to stay  Federal government continues to encourage development of National Electronic Healthcare Infrastructure National Health Information Network (NHIN)  – part of the federal government’s goal to digitize patients’ health records and designed on a common platform for health information exchange (HIE)  PDAs provide instant access to information at point- of-care
  75. Advantages and Disadvantages of EHR  Government mandate steps  Use all major functions of HER  Use EHR to send and receive clinical information  Learning Outcome: Contrast the advantages and disadvantages of electronic health records.  The federal government has mandated EHR for eligible Medicare providers by 2015.  There are financial incentives for providers who demonstrate “meaningful use” of EHR for Medicare or Medicaid patients until 2014.
  76. Continued Meaningful use includes the following steps:  Step 1 requires the provider to use all major functions of a certified EHR program.  Step 2 includes all of step 1 and adds that EHR must be used to send and receive clinical information such as lab orders and reports.
  77. Continued  clinical decisions support (in development)  High priority conditions  Enrolling patients in PHR  Accessing comprehensive data  Improving population health  E prescribing  Incentives
  78. 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
  79. Continued  Increased access to patient education materials  Decreased duplication of test orders  More efficient transfer of records  More efficient billing processes  Greatly decreased storage needs  Accessed from other locations  Physician’s home Satellite offices  Used in teleconferences
  80. Disadvantages of EHR Programs  Costly  Staff training  Requirement IT staff may be needed  Possible damage to system and software and or required upgrades
  81. Working With an Electronic Health Record  Basic rules unchanged  Creating a New Patient Record  Correcting an EHR  Be familiar with the hardware and software  Keep password secure  Check entries carefully before saving Learning Outcome: Illustrate the steps in creating a new patient record and correcting an existing record using EHR software. Refer to Points on Practice: Working with Electronic Health Records
  82. Other Functions of EHR Programs  Tickler files  Specialty specificCustomized  Templates  Learning Outcome: Describe some of the capabilities of EHR software programs.  Tickler Files Files that need periodic attention Alerts staff members about patients who are due for yearly checkups and patients who require follow- up care  Electronically scanned images of patient thumbprints or photos help keep track of records and assists with patient security by identifying the patient at the time of each visit.  Specialty Specific EHR software programs may be customized to suit a specific specialty and style of a physician’s office.  Templates or “check offs” enable the physician to add entire sentences or phrases with the click of a mouse, instead of typing the same information repetitively.
  83. Security and confidentiality of EHR  Access code  Limits access  Date and time stamp  Release of information policy  Backup
  84. Learning Outcome  Learning Outcome: Explain how you might alleviate a patient’s security fears surrounding the use of EHR .  All users have individual access codes and passwords.  The access code will allow each user to access only the areas of the record that the user is entitled to, based on job description.  Access codes insert a date and time stamp within the medical record, including the user’s initials, so that office administration and the patient may know who is accessing each medical record.  A procedure should be in place to document when someone requests information from the patient file, if the patient has given permission to release that information, and when it was released.  Protecting the confidentiality of patient records in computer files is the greatest concern of electronic health records. Electronic healthcare records should be kept just as secure as paper healthcare records.  Careful key entry is essential to maintaining accurate electronic health files.  Electronic files must be backed up on a regular basis to avoid accidental data loss.
  85. Other measure for security  Know the confidentiality and security features  No negativity  Pamphlet explaining HER  Show the patient his/her record  Explain access to patient
  86. Barriers to Adoption  Cost of conversion  Perceived lack of ROI  Technical and logistic challenges  Privacy and security concerns
  87. EHR Affect on Patient Care  Safety  Reduces the need to repeat tests  Reduces the number of lost reports  Supports provider decision making
  88. EHR Affect on Efficiency  Improves accessibility of patient information  Better data capture at the point of care  Integrates data from multiple internal and external sources  Facilitates the co-ordination of health care delivery
  89. EHR Affect on Patient Outcomes  Has the potential to  Improve the quality of patient care  Help providers practice better medicine  Provides seamless exchange of information among providers Component
  90. Summary  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.
  91. Question related to topic  Define EHR?  List the Purpose of EHR?  State the Model?  Enlist the type of EHR?  List out the terminology used in EHR?  Advantages of EHR?  Disadvantages of EHR?  Benefits of EHR?  Barrier of EHR?
  92. Short answer questions Define the concept of an electronic health record (EHR) EHR ?  – Collection of health information of patients that is stored in a digital format EHRs can interface with external computer programs List out the Models of EHR?  There are three distinct models of EHR programs – Distribution-based, Facility-based, and Web-based
  93. Fill in the blanks ------  Initial creation – -------1960s  Improved functionality – -----1970-1980  Practice management systems –---- 1990s  Government mandates – -----2010
  94. State the full form of Abbreviations  CPR—Computer-Based Patient Record  EMR—Electronic Medical Record  EHR—Electronic Health Record  CCD/CCR—Continuity of Care Document/ Continuity of Care Record  PHR—Personal Health Record  HIPPA-  HITEC-
  95. Objective type questions and answer  2004 – Bush created the ONC position  2008 – Medicare Improvements for Patients and Providers Act (MIPPA)  2009 – Health Information Technology for Economic and Clinical Health (HITECH) Act  2009 – Obama introduces economic recovery plan  2010– Beacon Community Cooperative Agreement  2010– Health Information Technology Extension Program
  96. What are the future changes of EHR LO 1.7 Describe potential developments in the future of the EHR National Health Information Network (NHIN) will provide a common platform Funding for EHR programs available through the Challenge Grants program The PDA, wireless networks, and high-speed Internet access will increase speed of access to information The Clinical data will no longer reside exclusively in a physician’s office, but will be available wherever the Internet is available to form the computer-based patient record (CPR)
  97. Questions and answer  What are the four errors that stem from communication problems?  ANSWER:  They are:  Lost or misfiled records  Mishandled patient messages  Inaccurate and illegible documents  Mislabeled or illegible lab or medication order Learning Outcome: List four medical mistakes that will be greatly decreased through the use of EHR.
  98.  PHI that is collected an maintained by the patient conforms to national interoperability standards not a legal record used by a single healthcare organization covered by HIPAA  ANSWER:  HER  PHR  EMR