Electronic Health Records Chapter 1

Questions and Answers

What does the acronym EHR stand for?

Emergency Health Report

Electronic Hospital Record

Electronic Health Report

Electronic Health Record (correct)

What is the definition of an EHR?

the portions of a patient's medical records that are stored in a computer system; aka electronic medical records, computerized patient records, or electronic chart.

Explain the benefits of EHR over paper charts.

Legibility of Notes, Accessibility of Charts, Transcription Costs Savings, Space Savings, Eliminate Staff, Eligibility for Pay-for-performance, New Physician Recruitment, Multiple Users Use a Chart Simultaneously, Lab Results Returned Automatically, X-Ray Results Returned Automatically.

What is trend analysis in the context of EHR?

comparing data from different dates, tests, or events to correlate the changes in the patient's health. Signup and view all the answers

What is decision support in the context of EHR?

Using interactive software tools to identify and select intelligent decisions and strategies. Signup and view all the answers

What are alerts in an EHR system?

reminders such as when the electronic prescription system generates an alert when two drugs known to have adverse interactions are prescribed for the same patient. Signup and view all the answers

What is health maintenance in an EHR system?

EHR system component to provide preventative health recommendations. Signup and view all the answers

Describe the patient check-in and check-out process at a physician's office.

... Signup and view all the answers

What points of the workflow differ between offices using paper and electronic charts?

choosing appropriate technology; project management; configuration needs; training needs; the case for quality; and return on investment. Signup and view all the answers

What are the differences between inpatient and outpatient EHR systems?

"Inpatient" means that the procedure requires the patient to be admitted to the hospital for monitoring, whereas "outpatient" does not. Signup and view all the answers

Describe the workflow associated with an Electronic Lab Order.

the clinician's order for a blood test is transferred to a uniquely numbered laboratory requisition, which records information about the patient, the clinician, and the test to be performed. Signup and view all the answers

Name at least three forces driving the change to EHR.

health and safety (IOM report/Leapfrog group), increasingly mobile society, increased specialization, internet, readiness for change, president appoints national coordinator for health information technology. Signup and view all the answers

What are the four goals of the Strategic Framework created by the Office of the National Coordinator for Health Information Technology?

Inform Clinical Practice, Interconnect Clinicians, Personalize Care, and Improve Population Health. Signup and view all the answers

Name some advantages of electronic prescriptions.

EP can include formulary decision support and DUR alerts to the prescribing physician, can prevent errors and save the doctor phone calls later. Signup and view all the answers

What is HL7?

Health Level 7-non-profit organization, leading messaging standard between healthcare systems. Signup and view all the answers

Study Notes

Electronic Health Records Overview

EHR stands for Electronic Health Record, representing patient medical records stored digitally.
EHRs include various names like electronic medical records, computerized patient records, and electronic charts.

Benefits of EHR

Improvements in legibility enhance communication among healthcare providers.
Considerable cost savings through reduced transcription expenses and space efficiency.
Facilitates recruitment of new physicians and eligibility for pay-for-performance incentives.
Enables multiple users to access and update charts simultaneously.
Lab and X-ray results are returned automatically, ensuring timely information.

Key Concepts in EHR

Trend Analysis: Involves comparing patient data over time to assess health changes.
Decision Support: Utilizes interactive software to assist in making informed clinical decisions.
Alerts: Generates reminders for potential drug interactions during prescriptions.

Health Maintenance

EHR systems provide preventative health recommendations to support patient wellness.

Patient Workflow in Healthcare Setting

The workflow encompasses patient check-in, information processing, examination, treatment, and check-out.

EHR vs. Paper Charts

Differences in workflow include technology selection, project management, training, and focus on quality and ROI.

Inpatient vs. Outpatient EHR Systems

Inpatient systems are utilized when a patient requires hospital admission for recovery monitoring.
Outpatient systems serve patients who do not require hospitalization and may offer treatments externally.

Electronic Lab Orders

The clinician's order for lab tests is documented via a laboratory requisition, ensuring precise patient and test information.

Forces Driving EHR Adoption

Key drivers include health and safety initiatives, a mobile society, increased medical specialization, internet availability, and governmental support.

Strategic Goals of Health Information Technology

Four core goals are to:
- Inform clinical practice
- Interconnect clinicians
- Personalize care delivery
- Improve overall population health

Advantages of Electronic Prescriptions

Electronic prescriptions enhance decision-making with formulary support and drug utilization review alerts to avoid potential errors.

HL7 Organization

Health Level 7 (HL7) is a nonprofit governing body focused on creating standards for messaging between healthcare systems.

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Description

Test your knowledge on Electronic Health Records (EHR) with this quiz based on Chapter 1. You will learn about the definition of EHR, its benefits over traditional paper charts, and more. Perfect for students and healthcare professionals alike!