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Electronic Medical Records
The document discusses electronic medical records (EMRs), defining them as digital versions of patients' paper medical charts that contain their medical history, diagnoses, treatments, test results, and other clinical data. EMRs allow authorized medical providers to securely access a patient's comprehensive medical record electronically. The document also outlines the key components, functions, and benefits of EMR systems, such as automating workflows, integrating with other healthcare IT systems, and facilitating data sharing across providers to support comprehensive patient care.
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Electronic Medical Records
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- 2. What is EHR? •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.
- 3. EHR • ISO TC215 defines an EHR as “a healthcare record in computer processable format.” EHRs are a vital part of health IT and can: • Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results • Allow access to evidence-based tools that providers can use to make decisions about a patient’s care • Automate and streamline provider workflow
- 4. Electronic Health Record(EHR): • An electronic version of a patients medical history, that is maintained by the provider over time,and may include all of the key administrative clinical data relevant to that persons care under a particular provider, includingdemographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiologyreports.
- 5. Electronic medical record •Should document history, examination, diagnoses intuitively, rapidly, efficiently • Should automate tests, medication, submission of diagnostic / procedure codes • Should include error checking rules to avert allergies / cross reactions
- 6. Electronic Medical Record •An EMR contains the results of clinical and administrative encounters between a provider (physician, nurse, telephone triage nurse, and others) and a patient that occur during episodes of patient care. Consequently, the EMR reflects the practice style, job function, knowledge and skill of the providers who create it. It necessarily includes data structures and data elements that reflect those providers' systems. • The Institute of Medicine defined the basic functions of an EMR, then known as the computer-based patient record (CPR). The Institute of Medicine's definition remains the gold standard
- 7. Electronic medical record •Evaluation and Management (E & M) electronic guidelines should be built into the code system • Should be compliant with HIPAA policies
- 8. EHR • One ofthe key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. • EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.
- 9. EHR Scope • EHRcontain patient-level data collected during and for clinical care. Data within the electronic health record include diagnostic billing codes, procedure codes, vital signs, laboratory test results, clinical imaging, and physician notes. With repeated clinic visits, these data are longitudinal, providing valuable information on disease development, progression, and response to treatment or intervention strategies. The nearly universal adoption of EHRs nationally has the potential to provide population-scale real-world clinical data accessible for biomedical research, including genetic association studies
- 10. EHR System Functions •Identify and maintain a patient record • manage patient demographics • manage problem lists • manage medication lists • manage patient history • manage clinical documents and notes • capture external clinical documents • present care plans, guidelines, and protocols • manage guidelines, protocols and patient-specific care plans • generate and record patient-specific instructions
- 11. Requirements of EHR •EHRs must include the following assumptions: • The relevant information of general interest should always be present, easy to access and extract from the general information. This is the case for both family and personal histories that are kept and increase/are added to over time so they can be used to inform clinical decisions, regardless of where they take place. • The limited temporal information generated in isolated events may be well supported in closed electronic documents. These documents may contain the particularities of each specialty or service provided, in terms of design and functionality, as part of each care episode.
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- 13. Framework of EMRsolutions
- 14. Stages of EMRcomplexity 1 2 3 0 eMAR CDR is the central pivot
- 16. EMR – NuesoftXpress
- 17. ChiroChart EMR –MediPro
- 18. EMR frontscreen –MediNotes
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- 21. EMR face sheet– AMBAS
- 22. EMR progress notes– AMBAS
- 23. EMR configuration –AMBAS
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- 27. RTS EMR –Customized page
- 28. RTS EMR –Electronic sign
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- 30. MDA Int MedicineEMR – ADS
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- 32. Pediatric EMR –MDS Medical
- 33. Pediatric EMR –MDS Medical
- 34. Pediatric EMR –MDS Medical
- 35. Oncology EMR –Synergy
- 36. Oncology EMR (Patientchart)
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- 40. 3-D EMR MappingEngine
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- 43. PMS – NuesoftXpress
- 44. PMS patient info– AMBAS
- 45. PMS scheduler –AMBAS
- 46. PMS online chargeslip – AMBAS
- 47. PMS + EMR– MedInformatix
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- 53. ADS MedicsElite –PDA access
- 54. EMR data entryin PDA
- 55. Conclusion • EMR isnot about just installing a few computers and storing patient data • EMR has to be integrated with PMS / EPM • EMR is all about automating WORKFLOW process
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- 59. Nature of bigdata in healthcare • Electronic health record (EHR) can empower progressed appraisal and offer assistance to clinical fundamental organization by giving colossal information
- 60. Conclusion •EMR is ultimatelygeared towards reducing errors, improving safety and care and cutting costs of healthcare