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Chapter 5
Electronic Health Records

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Evolution of Electronic
Health Records
Terms used to describe automated records
• Computerized medical record
• Computer-based patient record
• Electronic medical record
• Electronic health record

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Longitudinal Patient Record
A longitudinal patient record contains records
from different episodes of care, providers, and
facilities that are linked to form a view, over
time, of a patient’s health care encounters.

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Advantages of Manual Records
• Low start-up costs
• Training of staff is simple
• Requires less technically trained staff
• Available because there is no downtime

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Disadvantages of Manual Records
• Retrieval is not easily customized.
• Hand-written information can be difficult
to read.
• Difficult to abstract information
• Undocumented services are not easily
discovered until discharge analysis occurs.

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Advantages of Automated Records
• Improves access to patient information
• Multiple users can access patient information
simultaneously and remotely
• Eliminates paper record storage
• Improves readability
• Timely capture of data

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Advantages of Automated
Records (Continued)
• Views can be customized
• Updates occur easily
• Customized retrieval of information
• Enhanced security
• Reduction in administrative costs

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Disadvantages of
Automated Records
• Increased start-up costs
• Selection and development is time consuming.
• Staff training is time consuming.
• Staff training can be costly.
• Technical staff is needed.
• User resistance can occur.

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Transition to Electronic Records
• Scanning of documents
• Hybrid records
• Record transitional template

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Regional Health Information
Organization (RHIO)
A RHIO is an electronic network of patient
medical information gathered from multiple
health care organizations in a geographic
region.

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Stakeholders in a RHIO
• Hospitals
• Physicians
• Patients
• Health plans and insurers
• Public/governmental health agencies

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American Recovery
Reinvestment Act
Areas that the act will impact include:
• Incentives for adoption of EHRs
• Advancement of Health Information Exchange
• New privacy regulations
• HIM workforce opportunities

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Components of Electronic
Health Records
• Characters
• Fields
• Records
• Files
• Data
• Information

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Patient Registration Screen

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Administrative and
Clinical Applications
• Registration-admission-discharge-transfer system
(RADT)
• Clinical applications
– Patient monitoring systems
– Pharmacy
– Laboratory
– Radiology
– Nursing
– Medical documentation

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Patient Registration Demographic
Information

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Clinical Information:
Patient History

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Patient Intake Screen at Exam

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Transitioning to
Electronic Records
• Many challenges will have to be met.
• Health information professionals must have
an understanding of automated systems.
• Transitions to EHRs can take years.
• Facilities need to establish and develop
implementation plans.