The Electronic Medical Record


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  • The clinician must acquire information about the patient, make clinical decisions based on available information, and document and relay findings. To lay the foundation for supporting the full range of clinical activities with information technology, the successful medical school graduate should be able to do the following:
  • The Electronic Medical Record

    1. 1. The Electronic Medical Record: A Tool for Teaching Nancy B. Clark, M.Ed. Director of Medical Informatics Education, FSU College of Medicine For GRIPE Annual Meeting, 1/23/2003
    2. 2. Goals for this session <ul><li>AAMC Informatics Objectives </li></ul><ul><li>Selecting the EMR </li></ul><ul><li>Using the EMR in the CLC </li></ul><ul><li>Educational objectives </li></ul><ul><li>Hands on Experience </li></ul>
    3. 3. Resources/Reading <ul><li>Rakel, R. (2002) Electronic Medical Record. In: Rakel, R. Textbook of Family Practice, 6 th Ed. W. B. Saunders & Co. pp 1635-1645. Available in MDConsult. </li></ul>
    4. 4. AAMC MSOP Medical School Objectives Project <ul><li>Medical informatics’ use in five major roles played by physicians— </li></ul><ul><ul><li>Life-long Learner </li></ul></ul><ul><ul><li>Clinician </li></ul></ul><ul><ul><li>Educator/Communicator </li></ul></ul><ul><ul><li>Researcher </li></ul></ul><ul><ul><li>Manager </li></ul></ul><ul><li> (June 1998) </li></ul>
    5. 5. Role of Clinician <ul><li>Retrieve patient-specific information from a clinical information system, demonstrating the ability to display selected subsets of the information available about a given patient </li></ul>
    6. 6. Role of Clinician <ul><li>Make critical use of decision support, demonstrating knowledge of the available sources of decision support which range from textbooks to diagnostic expert systems to advisories issued from a computer-based patient record. </li></ul>
    7. 7. Role of Clinician <ul><li>Document and share patient-specific information, demonstrating the ability to record in information systems specific findings about a patient and orders directing the further care of the patient. </li></ul><ul><li>Use security-directed features of an information system </li></ul>
    8. 8. FSU Strategy <ul><li>No clinical activity – no real patients </li></ul><ul><li>Clinical Learning Center - simulated patients </li></ul><ul><ul><li>History Taking </li></ul></ul><ul><ul><li>Physical Exam </li></ul></ul><ul><ul><li>Documentation? </li></ul></ul><ul><li>Electronic Medical Record System! </li></ul><ul><li>Request for bids </li></ul>
    9. 9. Practice Partner <ul><li>Donated 40 user licenses </li></ul><ul><li>Established in 1985 </li></ul><ul><li>5000+ doctors using </li></ul><ul><li>30+ residency programs </li></ul><ul><li>Practice based research network </li></ul><ul><li>Decision Support </li></ul><ul><ul><li>Drug interactions </li></ul></ul><ul><ul><li>Drug allergy </li></ul></ul><ul><ul><li>Knowledge base links </li></ul></ul>
    10. 10. Practice Partner
    11. 11. Hardware Configuration Server Databases Wireless node Client Tablet PC
    12. 12. Using Tablet PC <ul><li>Wireless, touch sensitive handheld </li></ul><ul><li>Windows computer </li></ul><ul><li>Stylus </li></ul><ul><li>Cradle with keyboard and mouse </li></ul><ul><li>Used to score student performance </li></ul><ul><li>Used to access medical record and document encounter </li></ul><ul><li>Access medical information at point of care </li></ul>
    13. 13. EMR
    14. 14. Using Tablet PC
    15. 15. EMR Educational Objectives <ul><li>Access patient information </li></ul><ul><li>Documentation of Progress </li></ul><ul><li>Chronic Disease Management </li></ul><ul><li>Coding </li></ul><ul><li>Communication </li></ul><ul><li>Decision Support </li></ul><ul><li>Patient Education Handouts </li></ul><ul><li>Prevention/Health Maintenance </li></ul><ul><li>Security and Privacy </li></ul>
    16. 16. Simulated Patient Cases <ul><li>Past Medical History </li></ul><ul><li>Social History </li></ul><ul><li>Family History </li></ul><ul><li>Lab data </li></ul><ul><li>Multiple problems </li></ul><ul><li>Multiple medications </li></ul><ul><li>4 dimensional </li></ul><ul><li>Training site </li></ul><ul><ul><li>CLC </li></ul></ul><ul><ul><li>Doctoring small groups </li></ul></ul><ul><ul><li>PBL sessions </li></ul></ul><ul><ul><li>Lecture/grand rounds </li></ul></ul>
    17. 17. Quality Care Knowledge Management Clinical Information Management Order entry, EMR, Billing Communications Decision Support
    18. 18. Resources on EMRs <ul><li>Electronic Medical Records at AAFP </li></ul><ul><ul><li> </li></ul></ul><ul><li>Computerization at FPnet </li></ul><ul><ul><li> </li></ul></ul><ul><li>Computerized Medical Records </li></ul><ul><ul><li> </li></ul></ul>
    19. 19. Hands On Experience Using Practice Partner EMR