Handbook of Informatics for Nurses & Healthcare Professionals                                          Fifth Edition      ...
Learning Outcomes1. Define the term electronic health   record (EHR).2. Define the term electronic medical   record (EMR)....
Learning Outcomes5. Understand the significance of the 12   characteristics of the CPR defined by   the Institute of Medic...
Learning Outcomes8. List several concerns that must be   resolved before implementation of the   EHR.9. Recognize the rela...
Health Records• The traditional paper record does not  meet the needs of today’s healthcare  delivery system.     Handbook...
Electronic Health Record (EHR)• …“a longitudinal electronic record of  patient health information generated by  one or mor...
Other Electronic Record Terms• Numerous terms create confusion.• EHR has been used as a generic term  for all electronic h...
Other Terms•   Electronic medical record (EMR)•   Electronic patient record (EPR)•   Computer-based patient record (CPR)• ...
Electronic Medical Record (EMR)• “…legal record created in hospitals and  ambulatory environments that is the  source of d...
EMR Components•   Results reporting•   Data repository•   Decision support•   Clinical messaging and e-mail•   Documentati...
Levels of Automation• 0—Not all ancillary systems operational• 1—Major ancillary clinical systems up• 2—Major ancillary cl...
Levels of Automation• 5—BCMA + identification technology +  CPOE• 6—Physician documentation, DS, alerts,  PACS• 7—Fully el...
Electronic Patient Record (EPR)• Not necessarily a lifetime record• Focuses on current episode of care     Handbook of Inf...
Computer-Based Patient Record• CPR• Comprehensive lifetime record• Attributes identified by the Institute of  Medicine (IO...
EHR Attributes• Secure, reliable access where and when  needed• Records and manages episodic and  longitudinal information...
EHR Attributes• Captures data for:  – Quality improvement  – Utilization review  – Risk management  – Resource planning  –...
EHR Attributes• Captures information needed for  medical record and reimbursement  purposes• Longitudinal, masked informat...
EHR Collaborative• Charge: facilitate rapid input from the  healthcare community to support the  adoption of standards for...
Driving Forces for EHR• Client safety• Need to restructure healthcare delivery  system to improve the quality of care• Cos...
EHR Requirements• Technical standards• Clinical standards     Handbook of Informatics for Nurses & Healthcare Professional...
Meaningful Use•   Patient engagement•   Reducing racial disparities•   Improved efficiency•   Increased safety•   Coordina...
International Standards• The United States International  Organization for Standards (ISO)  Technical Committee’s 215 defi...
SNOMED• Systemized Nomenclature of Medicine  (SNOMED) clinical terms are seen as a  means to foster rapid development and ...
Continuity of Care Record (CCD)• Intended to improve continuity of care  when clients move between various  points of care...
Benefits of the EHR• Increases data integrity and quality• Increases productivity• Increases satisfaction for caregivers• ...
Benefits of the EHR• Better/faster data access• Supports research• Improved documentation• Prompts to ensure administratio...
Healthcare Enterprise Benefits• Better record security• Instant notice of eligibility/procedure  authorization• Decreased ...
Healthcare Enterprise Benefits• Better cost evaluation based on clinical  outcomes and resource utilization data• Decrease...
Consumer Benefits• Decreased wait time for treatment• Increased access/control over health  information• Increased use of ...
Consumer Benefits• Increased responsibility for own care• Alerts and reminders for appointments  and scheduled tests• Incr...
American Health Information    Community (AHIC)• Federal advisory body with charge to  make recommendations to the HHS  Se...
Current Status• No country has an operational EHR.• Bush called for adoption of the EHR by  2014.• Departments of Defense,...
Healthcare Information Technology     Standards Panel (HITSP)• Organization that is actively working on  harmonizing the d...
Summary• In summary, most of the potential  benefits associated with the use of  health information technology are  contin...
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Issues and Trends in HBI Ch14 pp

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Issues and Trends in HBI Ch14 pp

  1. 1. Handbook of Informatics for Nurses & Healthcare Professionals Fifth Edition CHAPTER 14 The Electronic Health Record Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  2. 2. Learning Outcomes1. Define the term electronic health record (EHR).2. Define the term electronic medical record (EMR).3. Define the term computer-based patient record (CPR).4. Discuss the similarities and differences between the EHR, EMR, and the CPR. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  3. 3. Learning Outcomes5. Understand the significance of the 12 characteristics of the CPR defined by the Institute of Medicine for today’s EHR.6. Discuss the benefits associated with the EHR.7. Review the current status of the EHR, including impediments. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  4. 4. Learning Outcomes8. List several concerns that must be resolved before implementation of the EHR.9. Recognize the relationship between meaningful use and the adoption and use of the EHR in hospitals, physician offices, and other settings. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  5. 5. Health Records• The traditional paper record does not meet the needs of today’s healthcare delivery system. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  6. 6. Electronic Health Record (EHR)• …“a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting….” (HIMSS, 2007)• Supports other care-related activities directly or indirectly—evidence-based decision support, quality management, and outcomes reporting Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  7. 7. Other Electronic Record Terms• Numerous terms create confusion.• EHR has been used as a generic term for all electronic health care systems. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  8. 8. Other Terms• Electronic medical record (EMR)• Electronic patient record (EPR)• Computer-based patient record (CPR)• CPR system• Shared electronic health record (SEHR) Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  9. 9. Electronic Medical Record (EMR)• “…legal record created in hospitals and ambulatory environments that is the source of data for the EHR.”• Long referred to single episode of treatment• Comprised of structured and unstructured data Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  10. 10. EMR Components• Results reporting• Data repository• Decision support• Clinical messaging and e-mail• Documentation• Order entry Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  11. 11. Levels of Automation• 0—Not all ancillary systems operational• 1—Major ancillary clinical systems up• 2—Major ancillary clinical systems + CDR• 3—Some documentation and retrieval• 4—CPOE, support for evidence-based practice Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  12. 12. Levels of Automation• 5—BCMA + identification technology + CPOE• 6—Physician documentation, DS, alerts, PACS• 7—Fully electronic paperless environment Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  13. 13. Electronic Patient Record (EPR)• Not necessarily a lifetime record• Focuses on current episode of care Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  14. 14. Computer-Based Patient Record• CPR• Comprehensive lifetime record• Attributes identified by the Institute of Medicine (IOM) provide the basis for today’s understanding of the EHR Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  15. 15. EHR Attributes• Secure, reliable access where and when needed• Records and manages episodic and longitudinal information• Primary information source during care• Assists with planning and delivery of evidence-based care Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  16. 16. EHR Attributes• Captures data for: – Quality improvement – Utilization review – Risk management – Resource planning – Performance management Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  17. 17. EHR Attributes• Captures information needed for medical record and reimbursement purposes• Longitudinal, masked information supports clinical research, public health reporting, and population health initiatives• Supports clinical trials and evidence- based research Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  18. 18. EHR Collaborative• Charge: facilitate rapid input from the healthcare community to support the adoption of standards for the EHR• Member organizations represent health informatics and professional organizations• Sponsored open forum meetings to solicit public input Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  19. 19. Driving Forces for EHR• Client safety• Need to restructure healthcare delivery system to improve the quality of care• Cost containment Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  20. 20. EHR Requirements• Technical standards• Clinical standards Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  21. 21. Meaningful Use• Patient engagement• Reducing racial disparities• Improved efficiency• Increased safety• Coordination of care• Measures to improve population health Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  22. 22. International Standards• The United States International Organization for Standards (ISO) Technical Committee’s 215 definitions of electronic medical and health records are used throughout most of the world but have not been adopted in the United States. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  23. 23. SNOMED• Systemized Nomenclature of Medicine (SNOMED) clinical terms are seen as a means to foster rapid development and adoption of standard clinical terminology for the EHR. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  24. 24. Continuity of Care Record (CCD)• Intended to improve continuity of care when clients move between various points of care• Comprised of summaries from many types of caregivers• “Snapshot,” not a comprehensive record Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  25. 25. Benefits of the EHR• Increases data integrity and quality• Increases productivity• Increases satisfaction for caregivers• Decreases redundant data collection• Allows data comparison from prior visits• Ongoing record• Supports decision support Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  26. 26. Benefits of the EHR• Better/faster data access• Supports research• Improved documentation• Prompts to ensure administration of treatments and medications• Supports trending• Supports automation of critical pathways• Improved efficiency Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  27. 27. Healthcare Enterprise Benefits• Better record security• Instant notice of eligibility/procedure authorization• Decreased need for record storage, x- ray film, filing• Faster turnaround for accounts Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  28. 28. Healthcare Enterprise Benefits• Better cost evaluation based on clinical outcomes and resource utilization data• Decreased length of stay• Increased compliance with regulatory requirements Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  29. 29. Consumer Benefits• Decreased wait time for treatment• Increased access/control over health information• Increased use of best practices/decision support• Increase ability to ask informed questions Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  30. 30. Consumer Benefits• Increased responsibility for own care• Alerts and reminders for appointments and scheduled tests• Increased satisfaction and understanding of choices Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  31. 31. American Health Information Community (AHIC)• Federal advisory body with charge to make recommendations to the HHS Secretary on ways to accelerate the development and adoption of health information technology• Chartered in 2005 Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  32. 32. Current Status• No country has an operational EHR.• Bush called for adoption of the EHR by 2014.• Departments of Defense, Health and Human Services, Veterans Administration, and Centers for Medicare and Medicaid Services mandated the EHR for their facilities and operations. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  33. 33. Healthcare Information Technology Standards Panel (HITSP)• Organization that is actively working on harmonizing the data standards that will allow the exchange of healthcare information Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  34. 34. Summary• In summary, most of the potential benefits associated with the use of health information technology are contingent upon the implementation of the EHR. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar

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