Healthcare Information Technologies

Healthcare Information Technologies

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M07_GART2674_01_SE_C07.QXD 7 8/10/09 1:58 PM Page 152 Electronic Health Records LEARNING OUTCOMES H I should be able to: After completing this chapter, you 䊏 Define electronic health records G 䊏 Explain why electronic health records are important G 䊏 Discuss what forces are driving the adoption of electronic health records S 䊏 Describe the functional benefits derived from using an EHR , EHR data 䊏 Compare different forms of 䊏 䊏 䊏 䊏 Describe different methods of capturing and recording data Explain why patient visits should be documented at the point of care S Explain how electronic signatures work Describe the workflow of H an office fully using EHRs A N ACRONYMS USED IN CHAPTER 7 I Acronyms are used extensively in both medicine and computers. The following C acronyms are used in this chapter. Q ABN Advance Beneficiary Notice HIPAA Health Insurance Portability and Accountability Act U AHRQ Agency for Healthcare Research and Quality Hx History A CDC Centers for Disease Control and Prevention CDR 1 Clinical Data Repository CMS Centers for Medicare 1 and Medicaid Services CPOE 0 Computerized Physician Order Entry; Computerized 5 Provider Order Entry T ICU Intensive Care Unit IOM Institute of Medicine of the National Academies LOINC® Logical Observation Identifiers Names and Codes OB Obstetrics PACS OR PAC SYSTEM Picture Archiving and Communication System CPRI Computer-Based Patient Record Institute S PIN Personal Identification Number CT SCAN Computerized Tomography Scan Px Physical Examination RHIO DUR Drug Utilization Review Regional Health Information Organization Dx Diagnosis Rx Therapy (Including Prescriptions) ECG OR EKG Electrocardiogram EHR Electronic Health Record HHS Department of Health and Human Services SNOMED-CT® SNOMED Stands for Systematized Nomenclature of Medicine; CT stands for Clinical Terms 152 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.qxd 8/22/09 5:09 PM Page 153 ELECTRONIC HEALTH RECORDS SOAP Subjective, Objective, Assessment, Plan Sx Symptoms Tx Tests (Performed) URI Upper Respiratory Infection 153 Evolution of Electronic Health Records The idea of computerizing patients’ medical records has been around for more than 30 years, but only in the past decade has it become widely adopted. Prior to the EHR, a patient’s medical records consisted of handwritten notes, typed reports, and test results stored in a paper file system. Though paper medical records are still used in many healthcare facilities, the transition to H electronic health records is under way. I Beginning in 1991, the IOM (which stands for the Institute of Medicine of the National Academies) sponsored studies and created reports that led the way G toward the concepts we have in place today for electronic health records. Originally, the IOM called them computer-based G names including electronic medpatient records.1 During their evolution, EHRs had many other ical records, computerized medical records, longitudinal patient S records, and electronic charts. All of these names referred to essentially the same thing, which in 2003, the IOM renamed as the , electronic health record or EHR. Institute of Medicine S The IOM report2 put forth a set of eight core functions that an EHR should be capable of performing: H 䊏 䊏 A Health Information and Data: Providing a defined data set that includes such items as N medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results; I providers when they need it. providing improved access to information needed by care C Result Management: Computerized results can be accessed more easily (thanQ paper reports) by the provider at the time and place they are needed. U Reduced lag time allows for quicker recognition and treatment of medical problems. Ait possible to reduce redundant The automated display of previous test results makes and additional testing. Having electronic results can allow for better interpretation and for easier detection of abnormalities, thereby ensuring appropriate follow-up. 1 Access to electronic consults and patient consents can 1 establish critical links and improve care coordination among multiple providers, as well as between provider and 0 patient. 5 䊏 Order Management: Computerized provider order entry (CPOE) systems canTimprove workflow processes by eliminating lost orders and ambiguities caused by illegible S handwriting, generating related orders automatically, monitoring for duplicate orders, and reducing the time required to fill orders. CPOE systems for medications reduce the number of errors in medication dose and frequency, drug allergies, and drug–drug interactions. The use of CPOE, in conjunction with an EHR, also improves clinician productivity. 1 R. S. Dick and E. B. Steen, The Computer-Based Patient Record: An Essential Technology for Health Care (Washington, DC: Institute of Medicine, National Academy Press, 1991, revised 1997, 2000). 2 Ibid. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 154 8/10/09 1:58 PM Page 154 CHAPTER 7 䊏 䊏 䊏 FIGURE 7-1 Data from digital spirometer transfers to EHR. (Courtesy of Midmark Diagnostics Group.) Decision Support: Computerized decision support systems include prevention, prescribing of drugs, diagnosis and management, and detection of adverse events and disease outbreaks. Computer reminders and prompts improve preventive practices in such areas as vaccinations, breast cancer screening, colorectal screening, and cardiovascular risk reduction. Electronic Communication and Connectivity: Electronic communication among care partners can enhance patient safety and quality of care, especially for patients who have multiple providers in multiple settings that must coordinate care plans. Electronic connectivity is essential in creating and populating EHR systems with data from laboratory, pharmacy, radiology, and other providers. Secure e-mail and web messaging have been shown to be effective in facilitating H communication both among providers and with patients, thus allowing for greater contiI nuity of care and more timely interventions. Automatic alerts to providers Gregarding abnormal laboratory results reduce the time until an appropriate treatment is ordered. G Electronic communication is fundamental to the creation of an integrated health record, both within a setting andSacross settings and institutions. , Patient Support: Computer-based patient education has been found to be successful in improving control of chronic illnesses, such as diabetes, in primary care. S is accomplished by means of electronic devices; examHome monitoring by patients ples include self-testing by patients H with asthma (spirometry), glucose monitors for patients with diabetes, and Holter monitors for patients with heart conditions. Data from monitoring A devices can be merged into the EHR, as shown in Figure 7-1. N I C Q U A 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 155 ELECTRONIC HEALTH RECORDS 䊏 䊏 155 Administrative Processes and Reporting: Electronic scheduling systems increase the efficiency of healthcare organizations and provide better, timelier service to patients. Communication and content standards are important in the billing and claims management area. Electronic authorization and prior approvals can eliminate delays and confusion; immediate validation of insurance eligibility results in more timely payments and less paperwork. EHR data can be analyzed to identify patients who are potentially eligible for clinical trials, as well as candidates for chronic disease management programs. Reporting tools support drug recalls. Reporting and Population Health: Public and private sector reporting requirements at the federal, H state, and local levels for patient safety and quality, as well as for public health, are more easily met with I computerized data. Eliminates the labor-intensive and time-consumingG abstraction of data from paper records and the errors that often occur in a manual process. G Facilitates the reporting of key quality indicators used for the internal quality improvement efforts of many healthcare organizations. S Improves public health surveillance and timely reporting of adverse reactions and , disease outbreaks. In addition to the IOM, ideas from CPRI and HIPAA help us define the EHR. S H Another early contributor to the thinking on EHR systems was the Computer-based Patient A an EHR: Record Institute (CPRI), which identified three key criteria for N 䊏 Capture data at the point of care. I 䊏 Integrate data from multiple sources. 䊏 Provide decision support. C Q HIPAA Security Rule The HIPAA Security Rule did not define an EHR, but perhaps U it broadened the definition. The Security Rule established protection for all personally identifiable health information stored in A electronic format. Thus, everything about a patient stored in a healthcare provider’s system is Computer-based Patient Record Institute protected and treated as part of the patient’s EHR. 1 1 In Electronic Health Records: Changing the Vision, authors Murphy, Waters, Hanken, and Pfeiffer define the EHR to include “any information relating to the past, present or future physical/mental 0 health, or condition of an individual which resides in electronic system(s) used to capture, transmit, 5 the primary purpose of providing receive, store, retrieve, link and manipulate multimedia data for health care and health-related services.”3 EHRs can include dental T health records as well. The core functions defined by the IOM and CPRI suggest that the EHR is not just what data is stored, but what can be done with it. In the broadest sense, S EHRs are the portions of a patient’s EHR Defined medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record. Social Forces Driving EHR Adoption Visionary leaders in medical informatics have been making the case for EHRs for a long time. However, the combination of several important reports caught the public’s attention and set in motion economic and political forces that are driving the transformation of our medical records systems. 3 Gretchen Murphy, Kathleen Waters, Mary A. Hanken, and Maureen Pfeiffer, eds., Electronic Health Records: Changing the Vision (Philadelphia: W. B. Saunders Company, 1999), 5. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 156 8/10/09 1:58 PM Page 156 CHAPTER 7 HEALTH SAFETY The IOM published a report stating: “Health care in the United States is not as safe as it should be—and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Errors also are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals. A variety of factors have contributed to the nation’s epidemic of medical errors. One oft-cited problem arises from H the decentralized and fragmented nature of the health care delivery system—or ‘non-system,’ to some observers. When patients see multiple providers in different settings, Inone of whom has access to complete information, it becomes easier for things to go G wrong.”4 These statements got the attention G of the press and public. They also got the attention of 150 of the nation’s largest employers. S Employers who sponsored employee health insurance programs had become , frustrated by the increasing costs of health insurance benefits for which they had little or no say about the quality of care. Following the release of the IOM report, these employers formed the Leapfrog group. S A study by the Center for Information Technology Leadership found more than 130,000 lifeH drug reactions alone. The study suggested that $44 billion threatening situations caused by adverse could be saved annually by installingAcomputerized physician order entry systems in ambulatory settings. Leapfrog created a strategy thatN tied purchase of group health insurance benefits to quality care standards. It also promoted CPOE I as a means of reducing errors. HEALTH COSTS GOVERNMENT RESPONSE The response C to the IOM report was swift and positive, within both the government and private sectors. Almost immediately, President Bill Clinton’s administration Qgovernment agencies that conduct or oversee healthcare issued an executive order instructing programs to implement proven techniques U for reducing medical errors, and creating a task force to find new strategies for reducing errors. Congress appropriated $50 million to the Agency for A Healthcare Research and Quality (AHRQ) to support a variety of efforts targeted at reducing medical errors. President George W. Bush followed through by establishing the position of the National 1 Coordinator for Health Information Technology, under the U.S. Department of Health and Human Services (HHS) to “develop,1maintain, and direct the implementation of a strategic plan to guide the nationwide implementation 0 of interoperable health information technology in both the public and private health care sectors that will reduce medical errors, improve quality, and produce greater value for health care5expenditures.”5 President Barack Obama identified T the EHR as a priority for his administration and signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act. S of EHRs and authorizes Medicare incentive payments The act promotes the widespread adoption to doctors and hospitals using a certified EHR and eventually financial penalties for physicians and hospitals that don’t.6 4 Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, 1999). 5 President George W. Bush, Executive Order #13335, April 27, 2004. 6 H. R. 1 American Recovery and Reinvestment Act of 2009, Title XIII Health Information Technology for Economic and Clinical Health, February 17, 2009. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 157 ELECTRONIC HEALTH RECORDS 157 Changes in the way we live have also made paper medical records outdated. In an increasingly mobile society, patients relocate and change doctors more frequently and thus need to transfer their medical records from previous doctors to new ones. Additionally, many patients no longer have a single general practitioner who provides their total care. Increased specialization and the development of new methods of diagnostic and preventive medicine require the ability to share exam records among different specialists and testing facilities. The Internet, one of the strongest forces for social change in the past decade, also affects healthcare. Consumers are becoming accustomed to being able to access very sensitive information securely over the web. They are beginning to ask “Why can’t I access my health records online?” Additionally, there are literally millions of health-related pieces of information on the web. Patients are arriving at their doctor’s office armed with questions and sometimes answers. Medical information previously unavailable to the average consumer is now as easy to access as searching Google™ or WebMD®. CHANGING SOCIETY H I Functional Benefits of an EHR G The ability to easily find, share, and search patient records G makes an EHR superior to a paper record system. However, remember the definition of EHR S as not just stored data but the functional benefits that can be derived from having that data accessible. Four benefits derived , from EHR data that cannot easily be achieved with paper records are health maintenance, trend analysis, alerts, and decision support. These will be described in a moment. First it is necessary to review the various forms in which EHR data is stored before exploring how these and other S functional benefits are derived from it. H Form Affects Functionality A An EHR with any form of data offers improved accessibility Nover a paper chart, but to achieve its full functional benefits, the computer must be able to quickly and accurately identify the information in the record. The form in which the data isI stored determines to what extent the computer can use the content of the EHR to provide additional functions that improve the C quality of care. Chapter 4 discussed various forms in which medical Q records are stored in the database. These may be broadly categorized into three forms: U 䊏 Digital images: This category includes scanned documents, A diagnostic images, digital 䊏 䊏 x-rays, and even annotated drawings or sound recordings. Images can be retrieved and displayed by the computer, but a human is required to interpret the meaning of the content. 1 Text: The second type of data includes word processing 1 files of transcribed exam notes and also text reports. It is principally obtained in the EHR by importing text files from outside 0 sources. The text files are useful for doctors and nurses to read 5 and can be searched by the computer for research purposes. However, text data is seldom used for generating alerts, trend analysis, decision support, or other real-time EHRTfunctions, because the search capability is slow and the results often ambiguous. S Discrete data: This third form of stored information in an EHR is the easiest for the computer to use. It can be instantly searched, retrieved, and combined or reported in different ways. Discrete data in an EHR may be subcategorized into fielded data and coded data. Coded data is fielded EHR data that goes a step further. By associating a code with each medical term and storing the appropriate code in the medical record, ambiguities about the clinician’s meaning are eliminated. Within medicine, many different terms are used to describe the same symptom, condition, or observation. Additionally, clinicians often use short abbreviations to document their observations in a patient chart. This makes it difficult for a computer to compare notes from one physician to CODED DATA Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 158 8/10/09 1:58 PM Page 158 CHAPTER 7 another. For example, exam notes by two different providers might phrase a knee injury problem differently: Dr. 1: “knee injury” Dr. 2: “knee trauma” A search of medical records for “knee injury” might not find the second record. To realize the full benefits of an EHR, it is necessary to record a code identifying the clinical information in addition to the text description. When a code is stored in the medical record, the record is considered codified. A codified EHR is more useful than a text-based record because it precisely identifies the clinician’s finding or treatment. The more parts of a medical record that can be codified, the more useful the data becomes to support additional functional benefits. STANDARD EHR CODING SYSTEMS H EHR data stored in a fielded, codified form adds significant value, but using a national standard code set instead of proprietary codes to codify the data will I records among systems, improve the accuracy of the better enable the exchange of medical content, and open the door to the functional benefits derived from having an electronic health G record. G EHR coding systems are called nomenclatures. EHR nomenclatures differ from other code S they are designed to codify the details and nuance of the sets and classification systems in that patient–clinician encounter. EHR nomenclatures are different from billing code sets in this , aspect. For example, a procedure code used for billing an office visit does not describe what the clinician observed during the visit, just the type of visit and complexity of the exam. EHR nomenclatures need to have a lot more S codes to describe the details of the exam; for this reason, they are said to be more granular. Two prominent nomenclatures H for EHR records are SNOMED-CT and Medcin®. Another prominent coding system, LOINC, isAused for lab results. Unfortunately, many hospital systems use none of these standard systems, having instead developed internal coding schemes applicable only to their facilities. These work N within the organization but create problems when trying to integrate other software or work withI a RHIO. SNOMED-CT SNOMED stands for C Systematized Nomenclature of Medicine; CT stands for Clinical Terms. SNOMED-CT is a medical nomenclature developed by the College of American Q Pathologists and United Kingdom’s National Health Service. It is a merger of two previous U codes. coding systems, SNOMED and the Read A Medcin Medcin is a medical nomenclature and knowledge base developed by Medicomp Systems, Inc., in collaboration with physicians on staff at the Cornell, Harvard, Johns Hopkins, and other major medical centers. The purpose of the Medcin nomenclature and the intent of the 1 standards. SNOMED-CT and other coding systems design differentiate it from other coding were designed to classify or index medical information for research or other purposes. Medcin 1 was designed for point-of-care usage by the clinician. Medcin is not just a list of medical terms, 0 but rather a list of findings (clinical observations) that are medically meaningful to the clinician. 5 enables the clinician to select fewer individual codes and An EHR system based on Medcin to quickly locate other clinical findings that are likely to be needed. This difference reduces the T time it takes to create exam notes and allows a physician to complete the patient exam note at the S time of the encounter. LOINC LOINC stands for Logical Observation Identifiers Names and Codes. LOINC was created and is maintained by the Regenstrief Institute, which is closely affiliated with the Indiana University School of Medicine. LOINC standardizes codes for laboratory test orders and results, such as blood hemoglobin and serum potassium, and also clinical observations, such as vital signs or EKG. LOINC is important because currently most laboratories and other diagnostic services report test results using their own internal, proprietary codes. When an EHR receives results from multiple lab facilities, comparing the results electronically is like comparing apples and oranges. LOINC provides a universal coding system for mapping laboratory tests and results to a common Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 159 ELECTRONIC HEALTH RECORDS 159 terminology in the EHR. This then makes it possible for a computer program to find and report comparable test values regardless of where the test was processed. Functional Benefits from Codified Records Because coded data is nonambiguous, the computer can use it for health maintenance, trend analysis, alerts, decision support, orders and results, administrative processes, and population health reporting. We will now explore four of the functional benefits that can be derived from using a codified EHR. HEALTH MAINTENANCE One of the best ways to maintain good health is to prevent disease, or if it occurs, to detect it early enough to be easily treated. Two important components of health maintenance are preventive care screening and immunizations. Preventive Care The simplest example of health maintenance is a card or letter reminding the patient that it is time for a checkup. In a paper-based office,Hcreating this reminder is a manual process. However, when a medical practice has electronic records, preventive screening can I become more dynamic and sophisticated. Health maintenance systems, also known as preventive G care systems, can go beyond simple reminders for an annual checkup. When an EHR has codified data, it can be electronically comG pared to the recommendations of the U.S. Preventive Services Task Force. S , U.S. PREVENTIVE SER VICES TASK FORCE S H A N I C Q U A The U.S. Preventive Services Task Force is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. The task force makes recommendations about preventive services based on age, sex, and risk factors for disease. Research has shown that the best way to ensure that preventive services are delivered appropriately is to make evidence-based information readily available at the point of care. The task force recommendations have been incorporated in EHR systems from several vendors. 1 1 0 5 T S FIGURE 7-2 Health Maintenance screen. (Courtesy of NextGen.) Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 160 8/10/09 1:58 PM Page 160 CHAPTER 7 Using a sophisticated set of rules, the EHR software compares the list of tests recommended for patients of a certain age and sex to previous test results stored in the EHR. It also calculates the time since the test was last performed and compares that to the recommended interval for repeat testing. A guideline unique to the patient is generated and displayed on the clinician’s computer. Using this information, the clinician can order tests, discuss important healthcare options, and recommend lifestyle changes to the patient at the point of care. Figure 7-2 shows the Health Maintenance screen from EHR vendor NextGen. It would be difficult to create standardized rules for the preventive care system if the tests were not coded using a standardized coding system. Preventive care screening guidelines are not H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 7-3 Cumulative summary report of blood tests from five different times. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 161 ELECTRONIC HEALTH RECORDS 161 limited to lab tests; other examples include mammograms, hearing and vision screening, and certain elements of the physical examination. Immunizations The other important component of preventive care is immunizations. Immunization slows down or stops disease outbreaks. Vaccines prevent disease in the people who receive them and protect those who come into contact with unvaccinated individuals. Immunizations must be acquired over time. Vaccines cannot be given all at once. Several require repeated applications over a period of time, and some such as the measles vaccine cannot be given to children under the age of 1 year. Therefore, the CDC and state health departments have designed a schedule to immunize children and adolescents from birth through 18 years. The CDC also publishes a recommended immunization schedule for adults. Adult immunizations are different from those given to a child. Using the codified data in an EHR, computers can compare a patient’s immunization history with the CDC-recommended vaccines and intervals and identify which immunizations the H letters to patient who haven’t patient needs. EHR systems can also scan the data and generate been in recently but may need to renew their immunizations.I In healthcare, laboratory tests are used G to measure the level of certain components present in specimens taken from the patient. When the same test is performed over a G period of time, changes in the results can indicate a trend in the patient’s health. With a paper chart, the clinician must page through theS reports and mentally remember the values to compare them. With an electronic health record, the, computer can find matching results in the data and generate a cumulative summary report or a graph, making it easier to compare test results from different times and dates. The cumulative summary report shown in Figure 7-3 S has three sections of results: blood gases, whole blood chemistries, and general chemistry. Within each section are the results from H above each column of data. tests performed five different times; the date and time is printed The report is read from left to right; each row contains A the name of the test component followed by result values for each of the five times. The right two columns are informational; they N test and the unit of measure. contain the range of values considered normal for each particular A simple graphing tool can turn numeric data in the EHR I into a powerful visual aid that would be impractical to create from a paper chart. Figure 7-4 provides an example of how data TREND ANALYSIS C Q Raj Patel – Total Cholesterol U A 250 FIGURE 7-4 Graph of total cholesterol from codified lab results. 1 1 0 5 T S 200 MG/DL 150 100 High Cholesterol Low 50 0 Feb-06 Mar-06 Apr-06 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 162 8/10/09 1:58 PM Page 162 CHAPTER 7 from multiple lab tests can be quickly extracted and graphed for the clinician. The value of the total cholesterol results over a three-month period of time is trended with the green line. The reference ranges of normal high (200) and low (140) values are shown in the graph as red and blue lines, respectively. The computer is able to generate this graph because the data is fielded and the different tests and components have unique codes. From all the possible tests a patient might have had, the computer can quickly find those coded as “total cholesterol.” Using a graph, the clinician can easily see the trend of this patient’s total cholesterol. Trend analysis is not limited to lab test results. Graphs of patient weight loss or gain are used as patient education tools. Effects of medication can be measured by comparing changes in dosage to changes in blood pressure measurements. Flow sheets (shown later in Figure 7-15) are another type of trend analysis tool. One of the important reasons for the widespread adoption of EHRs is the potential to Hand even electronic charts that are principally scanned reduce medical errors. Paper charts images depend on the clinician noticing I a risk factor about the patient. However, when an EHR consists primarily of fielded and codified data using standard nomenclature, rules can be set up G that allow the computer to do the monitoring. Alert is the term used in an EHR Gfor a message or reminder that is automatically generated by the system. Alerts are based on programmed rules that cause the EHR to alert the provider S when two or more conditions are met. For example, an electronic prescription system generates , adverse interactions are prescribed for the same patient. an alert when two drugs known to have Alerts can be programmed for just about anything in the EHR. However, the most prevalent alert systems are those implemented with electronic prescription systems. Interactions between multiple prescription drugs, allergic S reactions to certain classes of drugs, and patient health conditions that contraindicate certain drugs H can all contribute to suffering, additional illness, and in extreme cases even death. A consult the patient medication list, allergy list, and the To prevent this, most physicians Physicians’ Desk Reference (for interactions) before writing a prescription. As a further precauN tion, the pharmacy checks for drug conflicts and provides the patient with warning materials I written electronically, however, the computer can quickly about the drug. When prescriptions are and efficiently check for drug safetyC and present the clinician with warnings, alerts, and explanatory information about the risks of particular drugs. Figure 7-5 shows a clinical warning alert Q generated by the Allscripts EHR system. ALERTS FIGURE 7-5 Electronic prescription DUR alert. (Courtesy of Allscripts, LLC.) U A 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 163 ELECTRONIC HEALTH RECORDS 163 Drug Utilization Review When the clinician writing an electronic prescription selects a drug and enters the Sig7 information, the EHR system scans the patient chart for allergy information, past and current diagnoses, and a list of current medications. This information is then passed to a drug utilization review (DUR) program that compares the prescription to a database of most known drugs. The database includes prescription drugs as well as over-the-counter drugs, and even nutritional herb and vitamin supplements. The DUR program performs the following functions: 䊏 䊏 䊏 䊏 䊏 䊏 䊏 The drug about to be prescribed is checked against the patient medication list to determine if there is a conflict with any drug the patient is already taking. Certain drugs remain in the body for a period of time after the patient has stopped taking it. This latency period is factored in as well. Ingredients that make up the drug are checked against the ingredients of current medications to see if they conflict or would hinder the effectiveness of the drug. Drugs are checked for duplicate therapy, which occurs when H a patient is taking a different drug of the same class that would have the effect of an overdose. I Allergy records are checked for food and drug allergies that would be aggravated by the G new drug. Some drugs cannot be given to patients with certain medical G conditions; the patient’s diagnosis history is checked to see if such a situation would occur. S A patient education alert is created when the drug might be affected by certain foods or , alcohol interactions. If the Sig has been entered at the time of the DUR, then it is also checked to see if it matches recommended guidelines for the drug. Too much, S too little, too many days, or too many refills could cause overdosing, underdosing (causing it to be ineffective), or abuse. H If the DUR software finds any of these conditions, the clinician is given an alert message A explaining the conflict. The clinician can then alter the prescription or select a new drug, having never issued the incorrect one. N Formulary Alerts Another type of alert found in many EHR I prescription systems warns the clinician if the drug about to be prescribed is not covered by a patient’s pharmacy benefit Cwon’t pay for it, the patient may insurance. This is important because if a patient’s insurance choose not to fill the prescription or to take less than the amount Q prescribed. Insurance plans provide formularies indicating preferred, nonpreferred, and noncovered U drugs. If the clinician prescribes a drug that is not on the list, then when the patient tries to have the prescription filled, the pharmacy will call and ask the physician to change it. This causes an A inconvenience to the patient and wastes the doctor’s time. Instead a clinician using an EHR can select from a list of therapeutically equivalent drugs that are on the formulary of the patient’s 1 Figure 7-6 shows an Allscripts insurance plan and avoid writing an incorrect prescription. Therapeutic Alternatives alert. 1 Other Types of Alerts Electronic lab order systems can provide 0 alerts as well. For example, certain tests are not covered by Medicare. CMS requires that patients sign a waiver indicating that they were notified that a test would not be covered.5The waiver is called an Advance Beneficiary Notice (ABN). When certain tests are ordered, T the clinician is alerted if an ABN is required. Another example is an alert that monitors changes in values of certain blood tests and S pages a doctor whenever the value is outside of a certain range. Alerts can be generated by nonactions as well. Task list systems can notify an administrator when medical items are not handled in a timely fashion. CPOE systems can generate alerts when results for a pending test order have not been received within the time that it would normally require for that type of test. Once an EHR system contains codified data, an alert system is just a matter of programming a rule to watch for a certain event or detect a finding with a value above or below the desired limit. 7 Sig, from the Latin signa, are the instructions for labeling a prescription. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 164 8/10/09 1:58 PM Page 164 CHAPTER 7 FIGURE 7-6 Electronic prescription formulary alert. (Courtesy of Allscripts, LLC.) H I G G S , S H DECISION SUPPORT Physicians are trained to analyze information from a patient’s history, A physical exams, and test results for a medical decision. They are also accustomed to researching N an unusual case. However, the quantity of information the medical literature when faced with available to clinicians regarding conditions, disease management, protocols, case studies, and I treatments far exceeds their available time to read it. C of EHR systems to store or quickly locate materials relDecision support refers to the ability evant to the findings of the current case. Q These might include defined protocols, results of case studies, or standard care guidelines prepared by specialists, medical societies, or government U organizations. Decision support is not about “artificial intelligence” replacing a physician with a computer; A it is instead about providing help just when the clinician needs it. There are many examples of decision support systems, but let us look at four: 1 1drug formularies mentioned earlier. Formularies can be Decision support can include the used to look up drugs by name or 0 therapeutic class. Electronic prescription systems provide decision support to the clinician by comparing alternative brands that are therapeutically 5 information on costs, indications for use, treatment equivalent. They can also provide recommendations, dosage, guidelines, T and prescribing information. Medical References: S Prescriptions: 䊏 䊏 䊏 Decision support systems can provide quick access to medical references directly from the EHR. This can make access to evidence-based guidelines or medical literature as easy as clicking on a link in the chart. Protocols: Protocols are one form of decision support that can ultimately speed up documentation of the patient exam and improve patient care. Protocols are standard plans of therapy established for different conditions. With a decision support system, when a doctor has diagnosed a patient with a particular condition, the appropriate protocol appears on the EHR screen and all therapies are ordered with a click of the mouse. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 165 ELECTRONIC HEALTH RECORDS 䊏 165 Medication Dosing: Many medications have serious side effects, some of which must be monitored by regular blood tests. When both the medications and lab results are stored in the EHR as codified data, it is possible for decision support software to compare changes in medication dosing with changes in the patient’s test results. This assists the clinician in adjusting the patient’s medication levels to obtain the maximum benefit to the patient. Each of the functional benefits we have discussed—health maintenance, trend analysis, alerts, and decision support—are products of EHR systems that store medical records as codified, fielded data. It is only when these functional benefits are added to the clinical practice that the EHR approaches the vision of the IOM discussed at the beginning of this chapter. Capturing and Recording EHR DataH The value of having an EHR is evident, but how does the data I get into the EHR? In addition to scanning paper documents (discussed in Chapter 6) and the direct data entry of the exam note G (discussed later in this chapter), there are additional sources of EHR data that can be imported G directly into the system: 䊏 䊏 䊏 䊏 䊏 Lab test orders and results represent a significant portionSof the pages in a paper chart. Most reference labs have computerized both the orders and , results and have interfaces to their systems available. Electronic lab order and results systems can be interfaced to merge the test results directly into the patient’s chart. One benefit of electronic lab results described earlier S is that the numerical data that makes up many lab results lends itself to trend analysis, graphs, and comparison with other H allows providers to see the tests. The ability to review and present results in this manner immediate, tangible benefits of using an EHR. Not onlyA is the practice eliminating paper, but providers also should begin to realize the potential of conducting trend analyses with N an EHR. If some providers continue to use dictation/transcriptionI of exam notes, the word processing files in which that transcription is saved can be imported C directly as EHR text records. Also if a practice formerly used dictation/transcription and has retained those files, importQscanning the printed versions of ing them as EHR text records may be more efficient than those documents. Although these text records are not codified U like those created when clinicians enter actual data, they are at the very least more accessible and searchable than A scanned materials. Radiology studies are often dictated and transcribed. If the word processing files are available, they can be imported into the EHR as text records.1In some systems, digital images such as x-rays can be directly incorporated into the EHR and associated with the radiology 1 images can be made to report; or in facilities where a PAC system is used, diagnostic appear as part of the record, even though they are on a separate system. 0 Vital signs are numerical in nature and therefore eminently applicable to trend analysis and 5 graphing. These are especially useful for creating growth charts in pediatric practices and assisting adolescent and adult patients with weight loss T goals. Some of the modern devices used to take blood pressure readings, temperature, pulse, and respiration can automatically S transfer the readings to an EHR. Unfortunately, this level of automation is more prevalent in hospitals and ICU systems than in medical offices. The average medical office uses common instruments such as a scale, thermometer, and blood pressure cuff. The measurements are manually taken and recorded by a medical assistant. However, even without automated equipment, the medical assistant could enter the data in the computer instead of writing it on a sheet of paper. The patient’s problem list (acute conditions for which the patient was recently seen as well as chronic conditions such as high blood pressure or diabetes) may be able to be generated automatically from patient history and past visits, then simply updated by a nurse or doctor each time the patient is seen. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.qxd 166 8/24/09 6:10 PM Page 166 CHAPTER 7 FIGURE 7-7 Nurse enters data at patient’s bedside. H I G G S , S H can be entered directly by the patient on a computer in 䊏 History and symptom information the waiting room instead of on aApaper form on a clipboard. The patient-entered data is reviewed by the doctor during the exam and then merged into the EHR. This will be discussed in more detail later in theNchapter. 䊏 When clinicians use the EHR toI write prescriptions, the orders are also automatically recorded in the EHR as part of the C workflow. Another benefit of having the patient’s past prescriptions in the computer is that it makes renewing prescriptions much faster for the Q provider. U Documenting at the Point of Care A A goal of most EHR systems is to improve the accuracy and completeness of the patient record. One way to achieve this is to record the information in the EHR at the time it is happening. This is called point-of-care documentation. 1 In a physician’s office, this means completing the SOAP note before the patient ever leaves the office. In an inpatient setting, this means that nurses enter 1 vital signs and nursing notes at bedside, not at the end of their shift. Figure 7-7 shows a nurse entering notes while seeing the patient. 0 5 Leading physician experts on the EHR, Allen R. Wenner, an M.D. in Columbia, South Carolina, and John W. Bachman, an M.D. at the Mayo T Clinic, wrote: BENEFITS OF REAL-TIME DOCUMENTATION S Documenting an encounter at the point of care is the most efficient method of practicing medicine because the physician completes the medical record at the time of a patient’s visit. Dictation time is saved and the need for personal dictation aides is eliminated. Thus, point-of-care documentation is less expensive than traditional dictation with its associated high cost of transcription. In addition, the physician can sign the note immediately. Patient care is improved because the patient can leave with a complete copy of the medical record, a step that stimulates compliance. The delivery process is improved with point-of-care documentation because referrals can be accomplished with full information available at the time that the referral is needed. For these benefits to occur, Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 167 ELECTRONIC HEALTH RECORDS 167 the clinical workflow changes to improve efficiency, increase data accuracy, and lower the overall cost of healthcare delivery.8 The EHR system strives to improve patient healthcare by giving the provider and patient access to complete, up-to-date records of past and present conditions; it also enables the records to be used in ways that paper medical records could not. The sooner the data is entered, the sooner it is available for other providers and the patient. Nurse and Medical Assistant-Entered Data In hospitals of all sizes, nurses enter nursing notes, nursing assessments, and vital signs into the medical record. In ambulatory settings, the nurse or medical assistant takes the vital signs and discusses with the patient the reason for the visit, and possibly reviews allergy or medication information. Using an EHR, the nurse or medical assistant can initiate an exam record for the visit, enter the chief complaint, update any allergy records, make note of any medications the patient may have had prescribed elsewhere as well as any H over-the-counter medications being taken. In this way, a nurse or medical assistant helps to build Ithe EHR note without impacting the clinician’s time with the patient. G Patient-Entered Data G There are several things about documenting an encounter that become evident when the workS flow is studied. , 䊏 Only the patient has the information about what symptoms were present at the outset of the 䊏 䊏 illness and what the outcome of medical treatment of those symptoms was. The patient is also typically the source of past medical, S family, and social history, which is also recorded in the medical record. H Up to 67% of the nurse or clinician’s time with the patient is spent entering the patient’s A symptoms and history into the visit documentation. In the late 1980s, Dr. Allen Wenner wondered if a medical N history couldn’t be taken by a computer. The medical literature was replete with academic efforts at patient computer dialogue I beginning with Warner Slack at Harvard9 and John Mayne at Mayo Clinic.10 If the patients Cmore of the physician’s time to be entered their own data, it would free up clinical staff and allow focused directly on the important issues identified by the patient. Dr. Wenner confirmed the theQ ories of the academics—if given the opportunity, adding information to their medical chart while waiting was readily accepted by most patients. WorkingU with his colleagues at Primetime Medical Software, he developed Instant Medical History™, A an automated patient data-entry component for the EHR. It is available in many commercial EHR systems today. WORKFLOW USING PATIENT-ENTERED DATA Several workflows are compatible with Instant 1 on a kiosk or pen-tablet device in Medical History. Instant Medical History can be administered the waiting room, in a subwaiting area, in the exam room, or1at home via the web. Figure 7-8 shows a sample interview screen for Instant Medical History. To the patients, it represents a replacement of the clipboard with questions 0that the receptionist used to hand patients on arrival at medical offices. The difference is that the 5 questions are asked one at a time and can dynamically branch to other question sets based on the answers provided by the patient. T The computer calculates well and Patients complete the computer program at their own pace. can use the answers to several questions to branch to standardized screening instruments pubS lished in the medical literature. Patients have an opportunity to change their answers. 8 Allen R. Wenner and John W. Bachman, “Transforming the Physician Practice: Interviewing Patients with a Computer,” Chap. 26 in Healthcare Information Management Systems: Cases, Strategies, and Solutions, 3rd ed., ed. Marion J. Ball, Charlotte A. Weaver, and Joan M. Kiel (New York: Springer Science⫹Business Media, Inc., 2004), 297–319. Copyright © 2004 Springer Science⫹Business Media, Inc. New York. 9 W. V. Slack, G. P. Hicks, C. E. Reed, et al., “A Computer-Based Medical-History System,” New England Journal of Medicine 274 (1966): 194–98. 10 J. G. Mayne, W. Weksel, and P. N. Sholtz, “Toward Automating the Medical History,” Mayo Clinic Proceedings 43 (1968): 1–25. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 168 8/10/09 1:59 PM Page 168 CHAPTER 7 FIGURE 7-8 Instant medical history on a kiosk in the waiting room. (Courtesy of Primetime Medical Software & Instant Medical History.) H I G G S , S H Patients can review their histories A (as shown in Figure 7-9) and are better prepared to interact with the physician. N Because interview software records subjective information from the patient, the data represents a more complete and accurate Ireflection of a patient’s complaints than a physician’s dictation after the visit. Another important element of history taking is the depth to which a patient is C asked questions. Dr. Wenner found that the use of computer interviews improves the quality of Q Because the process gives the patient time to remember the information presented by the patient. and record details, it is more complete. U A FIGURE 7-9 Summary screen allows patient to review answers. (Courtesy of Primetime Medical Software & Instant Medical History.) 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 169 ELECTRONIC HEALTH RECORDS 169 Once the patient has answered the questions, the information is organized for the provider in a succinct and easy-to-read format that becomes the starting point for the patient encounter. The clinician can review this output either on a computer screen or as a printout. After asking a few confirmatory questions, physicians can complete the medical history in the examination room while the patient is still present. The physician can add additional information as necessary and the exam note can be completed by the physician at the point of care. Because patients want their physicians to arrive at the best diagnosis, Dr. Wenner found that patients are willing to answer questions. Also, because the clinician reviews the information entered by the patient instead of having to enter it, more time is available for explaining the diagnosis and educating the patient. Thus, the patient’s time and effort to enter the data are rewarded. Allowing patients to enter their own history frees up the clinician’s time while improving the depth and quality of the information gathered. It is important to note that, although patients are entering their symptom and history information in the computer, they are not accessing the EHR so there H are no HIPAA security concerns. The patient-entered data is separate from the EHR system until it is reviewed and made part of I the exam note by the clinician or nurse. G Some medical offices imbed Instant Medical History in their website so that patients can complete the symptom and history interview G prior to their appointment using the Internet. In that case, the data will already be available to the clinician when the patient arrives S at the office. In some instances, the clinician can make medical treatment decisions without a , 5). face-to-face visit; these are called E-visits (discussed in Chapter ALTERNATIVE WORKFLOW P REVENTIVE HEALTH SELF-SCREENING S H A N I C Q U A Patient interview software can also perform the health maintenance preventive screening discussed earlier in this chapter. Because most patients wait 15 minutes to see a physician, it is medically appropriate to screen patients for compliance with health maintenance guidelines while they wait. In the course of a yearlong study, patients were invited to answer a few questions on the computer when they spoke to the triage nurse, but screening was completely voluntary. Over time, the software revealed the need for hundreds of tetanus shots, varicella vaccinations, Papanicolaou smears, and other preventive measures by asking patients simple questions about the duration since their last assessment. Preventive health screening is one of the identified benefits of an EHR. 1 1 begins to record the actual exam The core of the true codified EHR comes when the provider findings in a medical record program instead of dictating and0having it transcribed later. Though it takes more of the provider’s time to enter the information in the computer, some physicians see the time spent entering the EHR as a reasonable trade-off for5 the time spent dictating and reviewing transcribed documents. T Entering observations and findings as medical data into an EHR has many additional advanS One of these is the correct calcutages for the provider than just the elimination of transcription. Clinician-Entered Data lation of billing and diagnosis codes. Government and private insurance claims have strict rules about what (evaluation and management) billing codes are allowed based on the documented level of an exam. Most EHR systems have built-in functions that help the provider select the correct billing code based on the data entered in the exam note. Many of these systems can automatically transfer the codes to the billing system when the exam is completed. This subject will be covered further in Chapter 9. SAVING CLINICIANS’ TIME Because the physician’s time with the patient is very valuable, the method used to document the exam must be optimized to be as efficient as possible. Usually this is achieved by a combination of features in the application software and the medical nomenclature. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 170 8/10/09 1:59 PM Page 170 CHAPTER 7 FIGURE 7-10 EHR systems use tabs to logically group findings. H I G G S , S H Most EHR systems designed for real-time data entry have the user select a finding (a medical term A or phrase the clinician wants to record). However, to be successfully used in real time, an EHR must make it easy for the clinician toN locate the correct finding. EHR vendors work constantly with I EHR users to devise means to locate and present findings when they are most likely needed. Most EHR systems designed for point-of-care data entry use some or all of the features discussedC next to help speed up data entry. Q nomenclature allows the clinician to select the desired NOMENCLATURE Use of a standardized terminology, minimizes the need to type, U and creates a codified medical record behind the scene. When the clinician selects a finding, the EHR may display several sentences describing the Alanguage. patient’s condition in precise medical EHR nomenclatures designed for point-of-care data entry, such as Medcin, also contain links between related findings, making possible the search-and-prompt features described below. The EHR shown in Figure 7-10 1 is based on the Medcin nomenclature. The screen layout and functional behavior are similar to many 1 EHR systems. The screen is divided into four functional sections. Two rows of icons across the top of the screen (called a toolbar) are used to quickly 0 access special features. The center portion of the screen consists of two (white) panels. The left panel displays the Medcin nomenclature. 5 The clinician records findings by clicking the red or blue button next to a finding. The text of that finding then appears in the right panel, which disT plays the actual patient exam note as it is being created (see Figure 7-11). The bottom portion of Sfor adding details about a finding. the screen contains two rows of fields EHR nomenclatures contain hundreds of thousands of findings. It would be extremely inefficient to have to scroll or search through the entire nomenclature each time the clinician wanted to record a finding. Therefore, it is more useful to present only a portion of the nomenclature at a time. Tabs in the left panel of Figure 7-10 (circled in red) are used to logically group the nomenclature into six broad categories. The tabs are organized to accommodate the SOAP format and labeled with abbreviations familiar to medical personnel: 䊏 䊏 Sx which stands for symptoms Hx which stands for history Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 171 ELECTRONIC HEALTH RECORDS 171 FIGURE 7-11 List (in left panel) of symptoms typical for upper respiratory infections. H I G G S , S H 䊏 Px which stands for physical examination A 䊏 Tx which stands for tests performed N 䊏 Dx which stands for diagnosis and includes syndromes and conditions I 䊏 Rx which stands for therapy (including prescriptions). C Separating the nomenclature in this way limits the list to findings relevant to the task. For Q example, in Figure 7-10 the Sx tab is selected, limiting the list to symptoms. If the Dx tab were selected, only findings that would be used for diagnosis would U be displayed. A the same condition, physicians LISTS Because many medical offices see a lot of patients with tend to perform the same type of exam, look for the same findings, order the same tests, and prescribe from a short list of treatments recommended for that condition. Therefore, it is logical for the practice to create shorter, quicker methods of locating1the necessary findings, by the type of exam or condition. 1 This is not “canned medicine.” These are templates to display findings that the doctor uses 0 most frequently for different types of conditions or diseases, so that the exam can be documented with minimal navigation or searching. For example, a pulmonary 5 specialist sees primarily respiratory cases, nephrologists see patients with kidney problems, and during the cold and flu season T family physicians see many patients with upper respiratory infections (URIs). S Lists are just subsets of the full nomenclature. The full nomenclature remains available if the physician needs to record a finding not showing on the list. Figure 7-11 shows a list used for patients with URIs. Separate lists can be created for each type of exam and for each medical condition that the practice commonly sees. Lists are dynamic and can contain an unlimited number of findings. Lists can include findings for every section of the SOAP note, so as to quickly document the complete visit. The concept of forms is to display a desired group of findings in a presentation that allows for quick entry of not only positive and negative findings, but of any additional detail, such as the date of onset or a value such as the patient’s weight. FORMS Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 172 8/10/09 1:59 PM Page 172 CHAPTER 7 FIGURE 7-12 Short intake form speeds entry of past medical, family, and social history. H I G G S , S H Forms are made up of the same A nomenclature findings as are lists. In contrast to lists, which scroll dynamically, forms are static; that is, findings have a fixed position on the screen, and will N remain in that location every time the form is used. I lists always arrange findings in the appropriate tab (Sx, Another difference is that, whereas Hx, Px, Tx, Dx, and Rx), this is not C a requirement of forms. The form designer is free to put any finding anywhere on the form. This allows each form to be designed to for the quickest entry of data for a particular type of exam. Q For example, Figure 7-12 showsUa form that allows the nurse to quickly record the patient’s medical history and the patient’s family and social history on one page of the form, even though A sections of the note. the findings will appear in three different Because the findings are prearranged on forms, it is easier for the user to see that all the necessary findings have been checked. The form designer can even require the entry of certain fields before the user can close the page,1thus ensuring important information has been recorded. Forms also offer many additional features 1 to make recording the information even faster. These include check boxes, drop-down lists, pop-up calendars, and even free-text boxes to further com0 ment on a finding. The form method of data entry is 5 found in systems from nearly every EHR vendor. Its similarity to paper forms makes it familiar to users. Compare Figure 7-12 with the patient history T form shown in Chapter 5, Figure 5-4. FIGURE 7-13 Search for angina pectoris. S The search function provides a quick way for the clinician to locate a desired finding in the nomenclature. Search produces a list of the findings almost instantly. Search is a necessary feature because even when using a form or list for a routine exam it is not uncommon for the patient to ask about a second condition not related to the reason for the visit. In Figure 7-13, the search is for angina pectoris, a finding that would not be in the typical URI list. Search functions are standard in most EHR systems. One advantage of a standardized nomenSEARCH Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 173 ELECTRONIC HEALTH RECORDS 173 clature is that it includes synonyms that allow users to locate the correct finding even when searching by an alternative term for that finding. Within medicine many different words are used to describe the same symptom, condition, or observation; standardized nomenclatures help in several ways. Here are search features available in many popular EHR systems: 1. The search function performs automatic word completion, so if you search for knee but the finding is for knees, it will still find it. 2. The nomenclature includes an extensive list of synonyms, which are used in an alternate word search. For example, if you search for knee injury, the search results will also include findings for knee burns, knee trauma, and fractured patella, among others. 3. The search function identifies related findings in the other (SOAP) sections of the nomenclature, so that when you search for a word or phrase in a particular tab, related findings are automatically available in the other tabs. This meansHthat as the clinician proceeds through the exam, the other tabs may already have findings related to the searched term I available for selection. G EHR systems that use the Medcin nomenclature have an additional feature called “Prompt with current finding.” The prompt function allowsG the user to dynamically generate a list of clinical findings. S Figure 7-14 shows the result of using the prompt feature. In the previous example, the clini, cian searched for angina pectoris. Once the finding was displayed, the clinician highlighted the finding and then clicked the Prompt button (circled in red). A full list of all symptoms, history, physical exam, tests, medications, treatments, and diagnosis findings related to angina was then S instantly available for the doctor to select from. PROMPT H A N I C Q U A FIGURE 7-14 Prompt changes list to findings related to angina pectoris. 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 174 8/10/09 1:59 PM Page 174 CHAPTER 7 Flow Sheets Another important EHR feature is the ability for the provider to view and incorporate information from a previous visit to update it in the current exam. Flow sheets present data from multiple encounters in column form. The flow sheet format allows for a side-by-side comparison of findings over a period of time. A paper version of a nursing flow sheet was shown in Chapter 5, Figure 5-6. Some clinicians prefer to view a patient chart this way. When outpatients are seen for followup visits to previous exams, this can be a real time saver for the provider. It is also ideal for chronic disease management, such as diabetes, or long-term conditions such as pregnancy. OB offices use flow sheets to monitor pregnancy, because it affords them a view of the previous visits while documenting the current one. Many EHR systems generate flow sheets dynamically; however, not all EHR systems implement flow sheets in the same manner. EHR systems that do not have codified exam notes limit H When an EHR uses a codified nomenclature, it is possiflow sheets to lab results or vital signs. ble to create clinical flow sheets that I present findings from entire encounters in columns by encounter date. An example of a computerized flow sheet is shown in Figure 7-15. Gmade up of rows and columns of cells. The first column The flow sheet in Figure 7-15 is displays descriptions of findings forG the current patient. The date of the current encounter is at the top of the column. The remaining columns to the right display encounter data from previous S visits. The cells within the column display , the words POS (in red) or NEG (in blue), or a numerical value for the finding. A blank cell indicates no finding was recorded on that encounter date. By comparing the values recorded for a finding over several dates, it is easier to spot trends in the patient’s health conditions. It S is also easier to remember to recheck the same items during the patient’s current visit. Findings can be recorded for the current encounter in the first column H of the flow sheet as the examination proceeds. A Clinicians may order diagnostic tests in addition to the physical exam. In the plan N order medications or therapy. When clinicians order lab section of the note, the clinician may tests and write prescriptions within the I EHR system, those orders are automatically documented. ORDERS FIGURE 7-15 EHR flow sheet comparing findings for five dates. C Q U A 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 175 ELECTRONIC HEALTH RECORDS 175 New orders can also be compared to previous tests and medications given to the patient to alert the physician if there is a conflict. One time-saving feature that is typical in all commercial EHR systems is the concept of keeping a list of a clinician’s frequently used orders. This allows the clinician to write the entire prescription or lab order with a single click of the mouse. With thousands of tests that could be ordered and thousands of drugs to choose from, a clinician doesn’t have the time to go through a search of medications or tests to write an Rx or order a lab. Many clinicians find that they order a fairly narrow range of tests (appropriate to their specialty and patient population) and write prescriptions for only a small group of medications. It makes sense for clinicians to keep a list of the items they most frequently use from which they can select when writing the order. Protocols, also sometimes called order sets, are lists of tests, treatments, therapy, or plans of care recommended for certain conditions. Once the clinician has diagnosed the H of orders from which to select. patient in the assessment section, the EHR can present a list Unlike the list of frequently used orders discussed above, a protocol lists orders most appropriate I to the patient’s condition, even if they are not frequently ordered by the clinician. The use of G protocols or order sets helps the clinician quickly order and document the plan of care for the patient. Chapter 5, Figure 5-5, showed a paper form of a postop G neurosurgery order set. PROTOCOLS Electronic Signatures S , Once the electronic medical record has been completed, it must S be signed. All types of records in the patient’s chart must be signed by an authorized individual. In EHR systems those signatures H are electronic. An electronic signature is not a facsimile of the signature you create with a pen on paper, but rather a computer process that meets three criteria:A 䊏 N Message Integrity: Message integrity means the recipient must be able to confirm that the document has not I been altered since it was signed. C 䊏 䊏 Nonrepudiation: Q The signer must not be able to deny signing the document. U User Authentication: A The recipient must be able to confirm that the signature was in fact “signed” by the real person. The electronic signature process involves the successful1identification and authentication of the signer at the time of the signature, binding of the signature 1 to the document, and nonalterability of the document after the signature has been affixed. Only digital signatures meet all 0 three of these criteria. However, many of the records in an EHR system are not5stored documents. As we discussed in Chapter 4, they are rows of fielded data. What is displayed on the screen as a physical exam note may be in fact hundreds of computer records. Therefore,Tmost EHR systems do not produce a true digital signature for each note, but rather use a security Smechanism within the software to authenticate the signer, and then lock that group of records as “signed,” thereafter preventing further changes. Beyond the pure mechanics of the EHR signature system are the responsibilities of the healthcare organization and providers to make electronic signatures work. The organization must have clear policies regarding who can sign what types of orders and documents. Further, there must be processes for authenticating that the users are who they say they are, and finally, there must be clear policies regarding who can set up, credential, and grant signing permission to the users. Whether electronic signatures in a system are true digital signatures or a software mechanism for locking and protecting EHR system records, it is important for providers to follow the Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 176 8/10/09 1:59 PM Page 176 CHAPTER 7 policies and procedures of their facility. Most EHR systems have an internal audit trail of who creates each document and medical record. Always log on to the EHR as yourself. Always log off when you are through. Keep your passwords or PIN numbers private. 䊏 䊏 䊏 This will prevent someone else from signing medical records under your ID. Flow of an Office Fully Using EHRs Earlier in this chapter Dr. Wenner and Dr. Bachman stated that an EHR changes the workflow of a medical office. Figure 7-16 illustrates the workflow of a visit to an office that fully uses the H in EHR systems today, including patient participation in electronic capabilities that are available the process and the capabilities of the I Internet. Follow the arrows in the figure as you read the descriptions of the steps listed here: G 1. An established patient phones the doctor’s office and schedules an appointment. Internet alternative: PatientsGare increasingly able to request an appointment and receive a confirmation via the Internet. S 2. The night before the appointment, , the medical office computer electronically verifies insurance eligibility for patients scheduled the next day. 3. On the day of the appointment, the patient arrives at the office and is asked to confirm that the demographic information onSfile is still correct. 2 1 12 4 3 5 1 1 0 5 T S 11 10 9 FIGURE 7-16 H A N I C Q U A 6 8 7 Workflow in a medical office fully using EHRs. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 177 ELECTRONIC HEALTH RECORDS 177 4. A receptionist, nurse, or medical assistant asks the patient to complete a medical history and reason for today’s visit using a computer in a private area of the waiting room. The patient completes a computer-guided questionnaire concerning his symptoms and medical history. Internet alternative: Some medical practices allow patients to use the Internet to complete the history and symptom questionnaire before coming to the office. 5. When the patient has completed the questionnaire, the system alerts the nurse that the patient is ready to move to an exam room. The nurse measures the patient’s height and weight and records it in the EHR. Using a modern device, vital signs for blood pressure, temperature, and pulse are recorded and wirelessly transferred into the EHR. 6. Subjective: The nurse and patient review the patient-entered symptoms and history. Where necessary the nurse edits the record to add clarification or refinement. The physician enters the exam room and discusses the reason for the visit and reviews with the patient the information already in the chart. H 7. Objective: The physician performs the physical exam. The I clinician typically makes a mental provisional diagnosis. This is used to select a list or template of findings to quickly G record the physical exam in the EHR. The EHR presents a list of problems the patient reported G in past visits that have not been resolved. The physician reviews each, examining additional body systems as necessary, S and marks the improvement, worsening, or resolution of each problem. Assessment: Applying his or her training to the subjective and objective findings, the , clinician arrives at a decision of one or more diagnoses, and decides if further tests might be warranted. 8. Plan of treatment: The clinician prescribes a treatment, S medication, and/or orders further tests using the EHR. H If medication is to be ordered, the physician writes the prescription electronically. The A current drugs. The physician prescription is compared to the patient’s allergy records and is advised if there are any contraindications or potential problems. The prescription is N compared to the formulary of drugs covered by the patient’s insurance plan and the physician I is advised if an alternate drug is recommended (thereby avoiding a subsequent phone call from the pharmacist to revise the prescription). The prescription is then transmitted directly C to the patient’s pharmacy. Q A built-in function of the EHR accurately calculates the correct evaluation and management code used for billing. The billing code is confirmed Uby the physician and automatically transferred to the billing system. A When the visit is complete, so is the exam note. The physician signs the note electronically at the conclusion of the visit. 9. If lab work has been ordered, a medical assistant will obtain 1 the necessary specimen and the order is sent electronically to the lab. 10. Patient education: Because of the efficiency of the EHR1system, the physician has more personal time with the patient for counseling or patient education. In many systems the 0 provider can display and annotate pictures of body areas for patient education, and print 5 them so that the patient can take them home. T education material, medication When the patient is dressed, he or she is given patient instructions, and a copy of the exam notes from the current visit. Allowing the patient to S take away a written record of the visit enables better compliance with the doctor’s plan of care and recommended treatments. 11. The patient is escorted to the checkout area. If x-rays or other diagnostic tests have been ordered at another facility, the office staff may call on behalf of the patient and schedule the tests. If a follow-up visit has been indicated, the patient will be scheduled for the next appointment. 12. If lab tests were ordered, the results are sent to the doctor electronically, are reviewed on screen, and automatically merged into the EHR. If radiology or other diagnostic reports are sent to the practice electronically as text reports, they are imported into the EHR and can be reviewed by the physician. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.qxd 178 8/24/09 3:29 PM Page 178 CHAPTER 7 A REAL-LIFE STORY Experiencing the Functional Benefits of an EHR By Henry Palmer, M.D. Henry Palmer, M.D., specializes in internal medicine and is affiliated with Rush University Medical Center. I am a physician practicing at two locations, neither of which is where my computers are. I have computers in the exam rooms and I am documenting with the patients, but the data is going over the Internet into the servers in real time. Rush University Medical Center, like other large institutions, had many different computer systems in their departments. Trying to unite all these legacy systems was very difficult, but they wanted to be able to access all the information relatively easily from one system. Rush has a CDR or clinical data repository, which stores the data from various legacy systems. For example, the clinical notes section includes all of the radiology, ultrasound, stress testing, cardiology, and operative reports; these are transcribed reports, all text based. Lab results, however, come in as data. The results are imported automatically. You can set how far back in time you want to default your view of them. This is very handy because you are able to see the trends. You can also graph it. You can rearrange the view to see your results horizontally or vertically. It has demographic information for the patient, of course, and helpful information about admission and discharge. Let’s say I want to look at the admission from two months ago. I can highlight it and find out who the providers were for that admission, the insurance information for that admission as well as the diagnosis. Rush also has an order entry system. When you sign in, it automatically shows if you have a patient who is in the hospital. This is handy, particularly in the case of primary care physicians, because sometimes your patients get admitted without your knowledge. A patient may get admitted into the surgical service and you might never be called. The order entry screen first shows if there are any orders approaching expiration. It also asks me to authenticate any verbal orders I had given over the phone, but had not yet countersigned. I can pull up a patient and view results through the order system. I can look at results in different ways—results for the last five days, all the results since admission, or just the ones that were critical. I can see details about particular results, the normal ranges, and some additional information about how to interpret those results. When I write a medication order, it goes electronically to the pharmacy. The order system will also provide alerts to drug interactions or areas of concern the hospital has identified with the drug. When ordering potassium, for example, the system would advise you that it should only be given in a certain quantity if the patient is on certain medications that tend to increase potassium levels anyway. It is easy to order labs by just clicking one box. You can also order a consult. CPOE works. It’s not perfect, but in a large institution like this it has to work or it wouldn’t be used. H I G G S , S H FIGURE 7-17 Dr. Palmer reviews a CAT scan. A N Our PAC system eliminates the need to have to go down to Iradiology to see x-rays. On the average workstation you can view the images of the patients’ x-rays with reasonable definition. If you C want really fine detail, you can go to any of the high-definition Q monitors that are scattered around the hospital. You can also display the radiologist’s report. Reading the report will guide you U toward the areas of concern. A We also use an electronic signature program for signing off on charts. Basically this brings up the document, allows me to edit it, and I can finalize my signature. I can also indicate which doctors I want to receive copies of my document. The system will then automatically fax them to the doctors involved with the patient care. Decision support includes access to the Rush medical library from inside our system. You enter your search term and it will retrieve an index of the article. You can go directly to what you wanted to read, for example, the treatment or the diagnostic approach to the disease. One of the challenges as a primary care physician is that my patients are searching the Internet. They will often come in with research in hand and ask some very cogent questions. I think the downside can be that people assume that because they have read it on the Internet that it applies to them or that they know what to do with the information—and that is not always the case. The biggest problem I see in health information technology today is the segregation of records, particularly between inpatient and outpatient systems. When patients are admitted, their outpatient records are not there. Synchronizing those, I think, would be a big step forward and also eliminate redundancy in testing. 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 179 ELECTRONIC HEALTH RECORDS 179 Accessibility is not a problem in the EHR system because there is no chart to “refile.” Multiple providers can access the patient’s chart, even simultaneously; for example, a physician could review the previous lab results before entering the exam room, even if the nurse was currently entering vital signs in the chart. Chapter 7 Summary Evolution of Electronic Health Records by the IOM. The format of the data determines to what extent the data can be used dynamically by the computer to extend the EHR. The forms of data are broadly categorized into three types: Though electronic health records have been called by various names for the past 30 years, the acronym EHR is currently used as shorthand for the electronic health record. H By EHR we mean the portion of a patient’s medical 1. Digital image data (provides increased accessibility). records that is stored in a computer system as well as the func-I 2. Text-based data (provides accessibility and text search tional benefits derived from having an electronic health record.G capability and can be reformatted for display on differThe IOM put forth a set of eight core functions that an devices). G 3. ent EHR should be capable of performing: Discrete data, fielded and ideally codified (provides all S of the above plus the capability to be used for alerts, • Health information and data health maintenance, and data exchange). • Result management , The term codified refers to the system of assigning • Order management standard codes to medical terms that underlie the descrip• Decision support tion which is visible to the user. Codified records also • Electronic communication and connectivity S make it easy to find, share, and search patient records. • Patient support H EHR coding systems are called nomenclatures. EHR A nomenclatures differ from billing codes in that EHR nomenThe CPRI has identified three key criteria for an EHR: N clatures have many more codes used to describe the detail of the exam such as the symptoms, history, observations, and I plan. SNOMED-CT and Medcin are EHR nomenclatures. • Capture data at the point of care. • Integrate data from multiple sources. C LOINC is a nomenclature primarily used for lab tests. • Provide decision support. EHR software allows clinicians to document the patient Q exam by selecting findings for symptoms, history, physical Social changes driving the need for EHR include an increasingly mobile society, where patients move and changeU examination, tests, diagnoses, and therapy. The functional benefits of an EHR include health maindoctors more frequently. Additionally, patients today see mul-A tenance, trend analysis, alerts and decision support: • Administrative processes and reporting • Reporting and population health tiple specialists for their care. This means their medical record no longer resides with a single general practitioner who pro• Health maintenance improves patient health through vides their total care. Thus, the ability to share exam records1 prevention and disease management. Immunizations, and test results is important to the patient’s continuity of care. patient education, counseling on preventive measures, Healthcare organizations, medical schools, employers,1 and early detection through appropriate screening help and even the government have recognized the importance of0 patients live healthier lives. computerizing the various components of the medical Immunizations must be acquired over time. Using 5 record. Studies from the IOM and others have shown that a the data in the chart, the EHR compares the patient’s large number of deaths occur from preventable medicalT immunization history to the schedule recommended by errors; many are caused by not having access to the patient’s S the CDC (or state health department) to determine medical information. what vaccine is due and when. The EHR can help to improve patient health, the quality Disease prevention through periodic screening of care, and patient safety by providing access to complete, and early detection can also save lives. Health mainup-to-date records of past and present conditions. This tenance programs generate patient-specific guidelines enables EHR records to be used in ways that paper medical by comparing the electronic patient records to the recrecords cannot. ommendations of the U.S. Preventive Services Task Force. Using this information the clinician can order Functional Benefits of an EHR tests, discuss important healthcare options, and recThe form in which patient records are stored will affect the ommend lifestyle changes to the patient at the point ability to achieve the functional benefits of EHRs identified of care. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 180 8/10/09 1:59 PM Page 180 CHAPTER 7 • Trend analysis presents test results, vital signs, or other EHR data from several dates in a side-by-side comparison or graph that allows the clinician to spot trends in the patient’s health records. Examples of data presentations that are useful for trend analysis include cumulative summary reports, graphs, growth charts, and flow sheets. • Alerts are messages or reminders that are automatically generated by the EHR to make the provider aware of a special situation. For example an electronic prescription system generates a DUR alert when two drugs known to have adverse interactions are prescribed for the same patient. Other examples of alerts include drug formulary checking, alerts generated when lab results are outside the normal range, and alerts when an ordered test will require the patient to sign an ABN form. • Decision support refers to the ability of EHR systems to quickly access evidence-based information relevant to the findings of the current case. These might include defined protocols, results of case studies, or standard care guidelines prepared by specialists, medical societies, or government organizations. Drug formularies and dosing guidelines are also forms of decision support. These functional benefits are made possible by EHR data primarily consisting of codified records. When an EHR uses a national standard nomenclature for its codes, many other functional benefits can be realized, including reducing the time it takes for the clinician to document the exam and the ability to exchange data electronically in a RHIO. Capturing and Recording EHR Data Completely documenting a visit before the patient ever leaves the office is the easiest way to use an EHR and provides the most rewarding benefits from the system. A significant contribution of data into an EHR can come from sources other than direct entry by the clinic staff. Examples include word processed files from dictated exam notes that have been transcribed and electronic lab orders and results. Many healthcare organizations scan paper documents into the EHR. Though document images do not offer the benefits of a codified medical record, they do provide widespread accessibility and a means to include source documents for a complete electronic chart. Numerous studies have shown that patient-entered data can also become a significant contributor to the EHR for some of the following reasons: • Only the patient has the information about what symptoms were present at the outset of the illness and what the outcome of medical treatment of those symptoms was. • The patient is also the source of past medical, family, and social history. • Patient-entered data is a more accurate reflection of a patient’s complaints. • Patients who can review their histories are better prepared for the visit. • Patient-entered data is organized by the computer for the provider in a succinct and easy-to-read format that becomes the starting point for the patient encounter. • Up to 67% of the nurse or clinician’s time with the patient is spent entering the patient’s symptoms into the visit documentation. • It allows the clinician more time to discuss the treatment plan with the patient. EHR systems use features such as lists, forms, search, and prompt to preload the findings that are likely to be needed for each type of patient. H • I G G S ,• S H A N I C Q U A 1• 1 0 5 T S Lists: Lists allow the clinician or medical practice to view a subset of the nomenclature typically used for a particular condition or type of exam. Because shorter lists mean less scrolling, lists speed up data entry of routine exams. Lists are flexible and can contain as many findings as necessary to document a typical visit. Forms: Forms display a desired group of findings in a presentation that allows for quick entry of not only positive and negative findings but of entry details, such as a value or result. Forms also provide other features that lists cannot: 1. Forms are static; findings have a fixed position on forms and will consistently remain in that position, every time the form is used. 2. Findings from multiple sections of the nomenclature can be mixed on the same page of the form in any way to enable the quickest data entry. 3. Forms may include check boxes, drop-down lists, pop-up calendars, and even free-text boxes for recording comments. 4. Forms can control which findings are required and which are optional; every question on a form does not have to be answered for every visit. Search: The search function provides a quick way to locate a desired finding in the nomenclature. Search addresses semantic differences in medical terms in three ways: 1. The search function performs automatic word completion, so if you search for knee but the finding is for knees, it will still find it. 2. The nomenclatures includes an extensive list of synonyms, which are used in an alternate word search. 3. The search function identifies related findings in other tabs, so that when you search for a word or phrase in a particular tab, related findings are automatically available in the other tabs. • Prompt: This is short for “prompt with current finding.” The prompt feature generates a list of findings that are clinically related to a finding that was highlighted when Prompt was clicked. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:59 PM Page 181 ELECTRONIC HEALTH RECORDS 181 2. Nonrepudiation: The signer must not be able to deny signing the document. 3. User Authentication: The recipient must be able to confirm that the signature was in fact “signed” by the real person. • Flow sheets: When clinicians treat patients with longterm conditions, they sometimes prefer to use flow sheets to view data from multiple encounters in columnar form. This format allows for a side-byside comparison of findings over a period of time. • Orders: Electronic ordering systems allow a provider to write an order and document it in the exam note in one step. • Protocols: Sometimes called order sets, protocols are lists of tests, treatments, therapy, or plans of care recommended for certain diagnoses. The use of protocols or order sets helps the clinician quickly order and document the plan of care for the patient. Flow of an Office Fully Using EHRs Review Figure 7-16 and the associated description of the workflow of an office fully using an EHR. Notice how efficient it is when the patient, nurse, and doctor document the encounter at the point of care. Patient care is improved because orders and results transmitted electronically save time and can help prevent medication errors and duplicate H tests. Patient compliance is improved when the patient can Electronic Signatures I leave with a complete record of the visit and relevant patient When the clinician has completed an exam note or signs an education materials. order in an EHR, it is signed electronically. A valid elec-G tronic signature must meet three criteria: G 1. Message Integrity: Message integrity means the recipient must be able to confirm that the document has not been altered since it was signed. S , S H 1. The topic of electronic health records is frequently inA the news. Describe something you have read or seen on TV about EHRs. N your medical history on a 2. How would you react if your doctor asked you to fill out computer instead of a paper form? Do you think there Iare some people who would have difficulty with this? If so, give examples. C Q U A 7 Testing Your Knowledge of Chapter Critical Thinking Exercises 1. What is the definition of an EHR? 2. What is advantage of codified data over document imaged data? 3. Name at least three forces driving the change to the EHR. 4. List the three criteria of an electronic signature. 5. List at least two ways codified data in the EHR can be used to manage and prevent disease. 6. What is a flow sheet? 7. What is a nomenclature? 1 1 0 5 T S Px ____________________________________________ Tx ____________________________________________ Dx ____________________________________________ Rx ____________________________________________ Name at least two benefits of having patients entering their own symptoms and history into the computer. 15. Describe at least two differences between lists and forms. 10. 11. 12. 13. 14. The tabs on the left of the EHR screen are used to logically group findings. The tabs have medical abbreviations. Write the meaning of each of the following: 8. Sx ____________________________________________ 9. Hx ____________________________________________ Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. Instructions: This assignment must be done in APA format. A minimum word count of 300 words (not including references) is required. A minimum of 3 references (with in-text citations) is required. Please make sure that scholarly references are used. If you have any questions please feel free to ask. 1. What is the definition of an EHR? Do an analysis of at least three forces driving the change to the EHR (root cause analysis). Provide research sources to support your analysis 2. List the three criteria of an electronic signature. Why are these required? 3. List at least two ways codified data in the EHR can be used to manage and prevent disease. Give specific exampl…
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