HTH 2304, Introduction to Health Information Management 1
Course Learning Outcomes for Unit III
Upon completion of this unit, students should be able to:
1. Discuss the legal aspects of health information management.
1.1 Discuss legal issues that impact electronic health records.
7. Assess the impact of emerging health information technology applications on the healthcare industry.
7.1 Discuss the technology changes from paper documentation to electronic documentation.
Course/Unit
Learning Outcomes
Learning Activity
1.1
Chapter 5
Article: “Redefining the ‘Legal Medical Record’ and How to Be Prepared to
Respond to Legal Requests for a Patient’s Legal Medical Record”
Unit III Assessment
7.1
Unit Lesson
Chapter 5
Article: “We Want People to have Access to Their Medical Data on Their
Smartphones”
Unit III Assessment
Reading Assignment
Chapter 5: Electronic Health Records
Additional Reading Assignment:
In order to access the following resources, please click the links below.
Arndt, R. Z. (2017). We want people to have access to their medical data on their smartphones. Modern
Healthcare, 47(34), 30. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest-
com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1931806312/AB94CC8C67B04
D08PQ/1?accountid=33337
Finkelstein, M. M., Esq. (2017). Redefining the “legal medical record” and how to be prepared to respond to
legal requests for a patient’s legal medical record. The Journal of Medical Practice Management:
MPM, 33(1), 11–14. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest-
com.libraryresources.columbiasouthern.edu/docview/1933854979?accountid=33337
Unit Lesson
Electronic Health Records
Health information systems are filled with patient data. Without patient data, there would not be a need for
health information systems. These data can take many forms, from a medical diagnosis to a therapeutic
regimen or from a laboratory result to a personal food diary. Through electronic record keeping, healthcare
providers and organizations are able to collect, organize, and analyze patient data to support and improve
clinical decision-making and to deliver more timely and effective care. Patients, too, are enjoying greater
UNIT III STUDY GUIDE
Electronic Health Records
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HTH 2304, Introduction to Health Information Management 1.docx
1. HTH 2304, Introduction to Health Information Management 1
Course Learning Outcomes for Unit III
Upon completion of this unit, students should be able to:
1. Discuss the legal aspects of health information management.
1.1 Discuss legal issues that impact electronic health records.
7. Assess the impact of emerging health information technology
applications on the healthcare industry.
7.1 Discuss the technology changes from paper documentation
to electronic documentation.
Course/Unit
Learning Outcomes
Learning Activity
1.1
Chapter 5
Article: “Redefining the ‘Legal Medical Record’ and How to Be
Prepared to
Respond to Legal Requests for a Patient’s Legal Medical
2. Record”
Unit III Assessment
7.1
Unit Lesson
Chapter 5
Article: “We Want People to have Access to Their Medical Data
on Their
Smartphones”
Unit III Assessment
Reading Assignment
Chapter 5: Electronic Health Records
Additional Reading Assignment:
In order to access the following resources, please click the links
below.
Arndt, R. Z. (2017). We want people to have access to their
medical data on their smartphones. Modern
Healthcare, 47(34), 30. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=https://
search-proquest-
com.libraryresources.columbiasouthern.edu/healthcomplete/doc
view/1931806312/AB94CC8C67B04
D08PQ/1?accountid=33337
Finkelstein, M. M., Esq. (2017). Redefining the “legal medical
record” and how to be prepared to respond to
3. legal requests for a patient’s legal medical record. The Journal
of Medical Practice Management:
MPM, 33(1), 11–14. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=https://
search-proquest-
com.libraryresources.columbiasouthern.edu/docview/193385497
9?accountid=33337
Unit Lesson
Electronic Health Records
Health information systems are filled with patient data. Without
patient data, there would not be a need for
health information systems. These data can take many forms,
from a medical diagnosis to a therapeutic
regimen or from a laboratory result to a personal food diary.
Through electronic record keeping, healthcare
providers and organizations are able to collect, organize, and
analyze patient data to support and improve
clinical decision-making and to deliver more timely and
effective care. Patients, too, are enjoying greater
UNIT III STUDY GUIDE
Electronic Health Records
https://libraryresources.columbiasouthern.edu/login?url=https://
search-proquest-
com.libraryresources.columbiasouthern.edu/healthcomplete/doc
view/1931806312/AB94CC8C67B04D08PQ/1?accountid=33337
https://libraryresources.columbiasouthern.edu/login?url=https://
search-proquest-
com.libraryresources.columbiasouthern.edu/healthcomplete/doc
5. electronic system, healthcare professionals can access them
quickly and print them easily.
A variety of formats emerged for this electronic record keeping
of patient data. The most prominent ones are
known as the electronic health record (EHR), the electronic
medical record (EMR), and the personal health
record (PHR). These are important terms in the healthcare
arena. In this unit, we explore the similarities,
differences, and interrelationships among these three types of
electronic record keeping. In addition, we cover
the hardware, software, and personnel needed to support EMRs,
EHRs, and PHRs, as well as the role of
change management in the successful implementation of health
information technology (Bowie &
Green, 2016).
Similarities, Differences, and Interrelationships of EHR, EMR,
and PHR
Electronic medical records (EMRs), electronic health records
(EHRs), and personal health records (PHRs)
are all digital approaches to recording information related to
patient care. They all have the benefit of easy
access to data, making it possible to provide quality care by
healthcare professionals. EMRs and EHRs
provide automation of care and decision support. EMRs have
been described essentially as replacements for
paper charts (Bowie & Green, 2016). They are often used in
hospitals and outpatient settings and are
encounter-based. EMRs include laboratory and imaging reports,
consultations, history and physical reports,
and prescriptions. The individual healthcare organization owns
the EMRs (Bowie & Green, 2016). The
movement of paper copies to electronic records makes it easier
to gain access to the files. This saves
6. numerous hours spent looking for a file that has been misplaced.
Having more time allows more patient to
physician contact, which can benefit the healthcare facility and
the patient.
EHRs provide more detailed information about the
patient that can come from multiple encounters at
different locations and can span a lifetime. Data
include demographics, medical diagnoses,
medications, vital signs, immunizations, and
progress notes, among others. EHRs can be
owned by the patient or other stakeholders like
hospitals, clinics, or insurance companies. Any
person providing health support services to the
patient can enter data into the EHR through an
interface. The patient can also access this data.
EHRs have added benefits for quality
management, outcome reporting, and research
(Hebda & Czar, 2009). Reporting outcomes means
giving the end result. Paper files were not easy to
access, easily lost, and did not allow for great
quality management. This has all changed with the use of
electronic files, which makes it easier to gain
access to files and manage these files. This increases
management skills by allowing more time to focus on
the needs of the patients.
Repetitive data like frequent vital signs, hourly intake and
output, and continuous fetal heart rate monitoring
should not be included in EHRs as they can make them
cumbersome. Such data should be stored separately
with an interface to EHRs so they can be referred to as needed.
Storing data separately helps healthcare
professionals reach the information quicker.
7. By eliminating paper medical records and the associated issues,
patients and providers can benefit from
EHRs. Research has proven that doctors’ offices can realize
cost savings by reducing the pulling of paper
charts and the use of transcription services (Bowie & Green,
2016). This can also have a financial effect for
stakeholders by providing a return on investment. The quality of
health care can be improved through the
adoption and proper use of EHRs.
(Schweihofer, 2017)
HTH 2304, Introduction to Health Information Management 3
UNIT x STUDY GUIDE
Title
The EHRs support data collection, which can be used to show
what care has worked well in the past and
what has not. It also can be used with billing to see what type of
payments are received quicker, how contact
is made with the patient, and what seems to work well when it
comes data collection for billing. Quality
management is huge because it shows the management system
quality when being used, for instance, if
individuals using the system feel it is easier to maneuver and
has higher quality. An outcome report displays
the ending results, which shows the positive and negative
8. consequences. Planning for resources is having a
list of resources for different types of treatment. For example,
when it comes to breast cancer, a nurse
navigator will provide the individual with breast cancer
resources. It can help with the planning for wigs,
prescriptions, and medical bills. These collections of data can
be used to further research and gain knowledge
in other aspects of health care. For instance, this data can show
how direct clinical care has taken place, such
as the physician and patient contact. It is important for the
patient to have contact with the physician.
The challenge is to use the information appropriately by
protecting the information and preventing individuals
from gaining access to other patients’ information. The
information can be used to discriminate against the
human rights of the patient. The role of the healthcare manager
is important in administering appropriate
procedures during this process.
PHRs, which are owned and controlled by patients, provide a
central place to store heath information over a
lifetime. Data contained in PHRs include a list of health
problems, allergies, diagnostic tests, current
medications, emergency contacts, and self-reported measures
such as weight, blood glucose, and blood
pressures. PHRs are Web-based and can be accessed by the
patient or authorized persons from anywhere
(Bowie & Green, 2016). This makes it easier to obtain the
patient’s record at any time and at any place.
PHRs are particularly beneficial to patients with chronic or
multiple medical conditions. It helps them keep
track of all their visits, allergies, and medications so they are
able to provide this information to clinicians as
needed. They can also use this to set and achieve personal
9. health goals.
Change Management
The role of change management has been introduced in health
care over the recent years. Change
management includes the process to manage how people deal
with changes, like the introduction of new
technologies, in order to ensure successful implementation of
the changes. This has played the biggest role in
record keeping. There are change factors such as hardware,
software, and personnel when it comes to
EMRs, EHRs, and PHRs.
Hardware is defined as the computers that are used to house the
records that are being kept. The software
includes the systems used to house the records. The personnel
are the individuals that complete the duties
on hand to make sure the records are kept successfully. This
makes for a successful implementation of health
information technology, which is needed with the advancement
in health care.
Most individuals do not easily adapt to change, and this can be
hard at times when it comes to making rapid
and huge changes in a small amount of time. Change
management is put into place to make sure these
changes are successful and items are completed in a timely
manner. While some individuals are not open to
change, with changes in technology and health information,
adaption to the changes have to occur to stay up-
to-date.
Summary
With the move from paper charts to the electronic system, both
10. patients and healthcare professionals can
have access to a patient’s medical record at any time. Patients
can share previous diagnoses and methods of
care with different healthcare professionals, particularly when
moving to new cities. Healthcare professionals
can have a reliable medical history of a patient. The three
digital approaches to electronic records include
EMRs, EHRs, and PHRs. EMRs (owned by the healthcare
organization) include laboratory and imaging
reports, consultations, history and physical reports, and
prescriptions. EHRs provide more detailed
information about the patient, including demographics, medical
diagnoses, and medications. PHRs (owned
and controlled by patients) include lists of health problems,
allergies, diagnostic tests, and self-reported
measures such as weight.
HTH 2304, Introduction to Health Information Management 4
UNIT x STUDY GUIDE
Title
References
Bowie, M. J., & Green, M. A. (2016). Essentials of health
information management: Principles and practices
(3rd ed.). Boston, MA: Cengage Learning.
11. Hebda, T., & Czar, P. (2009). Handbook of informatics for
nurses and healthcare professionals (4th ed.).
Upper Saddle River, NJ: Pearson.
Schweihofer, S. [Stux[. (2017). ECG electrocardiogram medical
2270728 [Photograph]. Retrieved from
https://pixabay.com/en/ecg-electrocardiogram-medical-2270728/
Thomas, R. L. (2006). Learning the alphabet of healthcare IT.
Healthcare Financial Management, 60(3), 100–
102. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=http://s
earch.proquest.com.libraryresources.c
olumbiasouthern.edu/docview/196382662?accountid=33337
Suggested Reading
Please click the link below to access the PowerPoint
presentation, which accompanies the textbook reading
assignment.
Click here for the Chapter 5 PowerPoint presentation. Click
here for the PDF version.
https://online.columbiasouthern.edu/CSU_Content/Courses/Busi
ness/HTH/HTH2304/17C/PowerPoints/UnitIII_Chapter5_Presen
tation.ppsx
https://online.columbiasouthern.edu/CSU_Content/Courses/Busi
ness/HTH/HTH2304/17C/PowerPoints/UnitIII_Chapter5_Presen
tation.pdf