Chapter EHR.docx

Overview of Electronic Health Records (EHR) and Electronic Medical Records (EMR) ================================================================================ Electronic Health Records (EHR) and Electronic Medical Records (EMR) are significant advancements in healthcare documentation, replacing...

Overview of Electronic Health Records (EHR) and Electronic Medical Records (EMR) ================================================================================ Electronic Health Records (EHR) and Electronic Medical Records (EMR) are significant advancements in healthcare documentation, replacing traditional paper charts with digital formats. Although these terms are frequently used interchangeably, they have distinct differences in terms of their scope and functionality. The term EHR stands for Electronic Health Record, which refers to a digital version of a patient\'s medical history, including information such as diagnoses, medications, and treatment plans. On the other hand, EMR stands for Electronic Medical Record, which is a digital record of a patient\'s medical information within a specific healthcare organization An Electronic Medical Record (EMR) is a digital database that stores a patient\'s complete medical history within a specific healthcare facility. It encompasses clinical information such as diagnoses, medications, and treatment plans, resembling a digital version of conventional paper charts. On the other hand, electronic health records (EHRs) include a wider range of patient health information. These systems are specifically created to combine information from various healthcare providers and settings, allowing for extensive sharing and access across different organizations involved in patient care. The historical development and evolution of Electronic Health Records (EHR) and Electronic Medical Records (EMR) The development of EHR/EMR can be traced back to the 1960s, coinciding with the introduction of computer systems in healthcare environments. Originally employed for administrative functions such as billing and scheduling, these systems developed alongside technological progress. During the 1990s, a significant turning point occurred when the Institute of Medicine recommended the use of electronic health records to improve patient safety. The 2009 HITECH Act was designed to expedite the adoption of electronic health records (EHR) by providing incentives to healthcare providers who successfully implement and utilize certified EHR technology. Distinctions Between Electronic Health Records (EHR) and Electronic Medical Records (EMR) The main differentiation lies in their intended extent and operational capabilities: EMR systems are confined to a single healthcare practice and are designed to manage patient records and clinical workflows that are unique to that particular setting. They do not easily enable the exchange of data beyond the practice. Conversely, EHR systems are specifically designed to facilitate interoperability. They compile a patient\'s comprehensive medical records, incorporating data from diverse sources such as laboratories, specialists, pharmacies, and emergency facilities. This interoperability facilitates smooth coordination of care among various healthcare providers and settings. The significance of Electronic Health Records (EHR) and Electronic Medical Records (EMR) in contemporary healthcare. EHR/EMR systems are essential for improving healthcare delivery due to their numerous key advantages: 1. Enhanced Patient Care: By consolidating and regularly updating extensive patient information, these systems empower healthcare providers to make well-informed clinical judgments, thereby improving the quality and safety of patient care. 2. Improved Coordination: Electronic Health Records (EHRs) enable efficient and smooth communication among healthcare teams in various settings, guaranteeing consistency and logical progression in patient treatment plans. 3. Enhanced Efficiency: Digital records simplify administrative tasks, minimizing paperwork and reducing the administrative workload on healthcare providers. This high level of efficiency enables healthcare professionals to allocate more time towards providing direct patient care and engaging in meaningful interactions with patients. 4. Patient Engagement: Electronic Health Records (EHRs) enable patients to access their health information, encouraging their active involvement in the management of their healthcare requirements. 5. Data analytics: Electronic Health Record (EHR) systems facilitate the gathering and examination of data, aiding in research endeavors and endeavors to enhance healthcare practices and outcomes. Elements of EHR/EMR Systems --------------------------- Electronic Health Record (EHR) and Electronic Medical Record (EMR) systems are crucial for contemporary healthcare operations, as they consist of vital elements that enable thorough patient management and streamlined record-keeping. ### Essential elements The core components of EHR/EMR systems are responsible for capturing and organizing essential patient information. #### Patient Demographics This encompasses fundamental information such as the patient\'s name, age, gender, contact details, and insurance details, establishing a fundamental profile for medical records. #### Medical History A comprehensive collection of information documenting the patient\'s previous medical conditions, surgical procedures, allergies, and family medical history. This information facilitates healthcare providers in comprehending the patient\'s medical history. #### Medication and Allergy Lists Comprehensive documentation of both present and previous medications, encompassing specific details such as dosage and frequency, alongside recorded instances of allergies to medications or substances. These lists are of utmost importance to ensure the safety and accuracy of prescribing practices. #### Laboratory and Test Results Refers to the data obtained from diagnostic tests, imaging studies, and other clinical investigations. These results provide objective information about the patient\'s health condition and the effectiveness of their treatment. #### Clinical Notes Comprehensive records that document healthcare provider observations, progress notes, and specific details of ongoing treatment plans. They play a crucial role in maintaining continuity of care and facilitating effective communication among members of the medical team. #### Vital Signs Vitals to the essential recorded measurements, including blood pressure, heart rate, temperature, and respiratory rate, that are crucial for monitoring the health status of patients during visits and treatments. #### Immunization Records Documentation of vaccines that have been administered, as well as the schedules for future vaccinations and the immunization history. These records play a crucial role in supporting preventive care and public health efforts. #### Billing Information Financial records that are crucial for managing the finances of a healthcare facility. These records include information about patient visits, treatments, insurance claims, and reimbursement processes. #### Decision Support Systems These are tools that are integrated into the Electronic Health Record (EHR) or Electronic Medical Record (EMR) to help healthcare providers make well-informed clinical decisions. These decisions are based on evidence-based guidelines and patient-specific data. #### Scheduling Includes functionalities to effectively handle patient appointments, follow-ups, and reminders, thereby enhancing healthcare delivery and patient involvement. ### Specialized components Furthermore, EHR/EMR systems frequently incorporate specialized modules designed to cater to specific healthcare requirements: #### Chronic Disease Management Tools specifically created to monitor and control chronic conditions like diabetes or hypertension, making it easier to provide ongoing patient care and maintain good health. #### The Behavioral Health Modules Provide a range of features that support the treatment of mental health and substance abuse. These features include assessments, treatment plans, and progress tracking, all of which contribute to comprehensive patient care. #### Pediatric Modules Specifically designed features for managing child health, such as growth charts, developmental milestones, and guidelines for dosing medication in children, guaranteeing specialized care for younger patients. #### OB/GYN Modules Specialized tools designed to facilitate the management of pregnancy, childbirth, and women\'s health records. These modules encompass various aspects such as prenatal care, monitoring maternal health, and maintaining obstetric history. ### Interface Design and Accessibility The usability of EHR/EMR systems is crucial for their successful implementation and acceptance in healthcare settings. **Usability:** The system is designed with an intuitive interface and navigation features that reduce the amount of time healthcare providers need to spend learning how to use it. This ensures that the system can be efficiently used during patient encounters. **Customization:** The ability to adapt the interface to meet the specific requirements and preferences of healthcare practices and individual providers, enhancing workflow efficiency and user satisfaction. **Accessibility:** The EHR/EMR system allows healthcare providers to securely access patient information from different devices, including desktop computers, tablets, and smartphones, in order to conveniently retrieve data across different care settings. Advantages of Electronic Health Record (EHR) and Electronic Medical Record (EMR) Systems ---------------------------------------------------------------------------------------- Electronic Health Record (EHR) and Electronic Medical Record (EMR) systems provide multiple benefits that greatly enhance different aspects of healthcare provision, resulting in enhanced patient outcomes and operational effectiveness. ### Improved Patient Care Electronic Health Record (EHR) and Electronic Medical Record (EMR) systems greatly enhance patient care by providing healthcare providers with instant access to thorough and accurate patient information. This access provides assistance for: #### Enhanced Decision-Making By having access to comprehensive patient histories, healthcare providers are able to make informed and well-considered clinical decisions. This includes all previous medical conditions, treatments, allergies, and medication histories, guaranteeing that care plans are established on a comprehensive comprehension of each patient\'s health status. #### Reduced Errors The conversion from physical paper records to electronic formats significantly decreases the likelihood of errors that may occur due to illegible handwriting, misplaced files, or incomplete documentation. By utilizing digital records, the legibility, organization, and retrievability of information are improved, leading to increased accuracy of patient data. #### Enhanced Follow-Up Automated reminders and alerts integrated into Electronic Health Record (EHR) and Electronic Medical Record (EMR) systems are essential for ensuring proper patient follow-up care. These systems can alert healthcare providers regarding essential follow-up appointments, preventive screenings, and medication refills, guaranteeing that patients receive prompt and consistent care. Enhanced Effectiveness and Output --------------------------------- EHR/EMR systems optimize administrative processes, leading to a substantial reduction in the amount of time healthcare providers dedicate to paperwork and a consequent improvement in overall productivity. Systems streamline a range of administrative tasks, including appointment scheduling, billing, and prescription refills, resulting in time savings. This automation enables healthcare providers to dedicate more time to patient care rather than administrative tasks. Through the streamlining of processes and alleviation of administrative tasks, EHR/EMR systems facilitate healthcare providers in attending to a greater number of patients within a given time period, while maintaining the same level of care. This results in enhanced resource utilization and improved patient flow. Cost savings are achieved through the decreased reliance on paper, physical storage, and transcription services, resulting in substantial financial benefits for healthcare facilities. In addition, implementing efficient electronic billing and coding processes can improve revenue cycle management. Enhanced Integration of Healthcare Services Electronic Health Records (EHRs) enable efficient and smooth communication and coordination between various healthcare providers and organizations, ensuring that patient care is thorough and effectively integrated: EHRs facilitate comprehensive care by enabling all healthcare providers involved in a patient\'s treatment to access current and consistent information, thereby ensuring a shared understanding of the patient\'s medical history and treatment plans. This synchronized approach facilitates the delivery of more uniform and efficient care. Reduced Redundancy: Electronic Health Records (EHRs) minimize the necessity for duplicate tests and procedures by offering a comprehensive overview of a patient\'s medical history. This not only decreases healthcare expenses but also saves patients from unnecessary discomfort and inconvenience. Enhanced Transitions: Electronic Health Records (EHRs) facilitate seamless transfers of patients\' care among primary care providers, specialists, hospitals, and other healthcare facilities. Ensuring continuity is essential to preserve the effectiveness of treatment and ensure patient safety when transitioning between different healthcare providers. Active involvement of patients in their own healthcare and decision-making processes. Electronic Health Records (EHRs) enable patients to access their health information, promoting their active involvement in their healthcare: Enhanced Engagement: By granting patients access to their medical records, they are empowered to actively participate in the management of their own health. This engagement results in enhanced compliance with treatment protocols, improved health-related habits, and ultimately, superior health outcomes. Educational and awareness components are commonly integrated into Electronic Health Records (EHRs), providing patients with access to personalized health information and educational resources. This facilitates patients\' comprehension of their conditions and enables them to make well-informed choices regarding their healthcare. Electronic Health Record (EHR) systems commonly include secure messaging systems that enable seamless communication between patients and healthcare providers. Establishing a direct channel of communication can strengthen the relationship between patients and healthcare providers, guarantee prompt responses to patient inquiries, and enhance overall patient contentment. The incorporation of EHR/EMR systems into healthcare practices yields significant advantages, establishing the basis for enhanced patient care, operational effectiveness, and patient involvement. Comprehending these advantages is crucial for novice healthcare students as they get ready to navigate and contribute to the ever-changing field of healthcare technology. Challenges and Limitations of Electronic Health Record (EHR) and Electronic Medical Record (EMR) Systems -------------------------------------------------------------------------------------------------------- Although EHR/EMR systems provide various advantages, healthcare providers must address several challenges and limitations when implementing and using them. ### Expense Limitations Implementing an EHR/EMR system can incur substantial upfront costs, which can present a financial hurdle for numerous healthcare organizations. The expenses encompass: Acquiring the requisite technology entails procuring both the software and hardware necessary to sustain the system. This encompasses computers, servers, and additional peripheral devices that are responsible for ensuring the seamless operation of the system. ### Training It is crucial to provide instruction to employees on the proper utilization of the new EHR/EMR system, although this can incur significant expenses and require a substantial amount of time. Thorough training programs are necessary to ensure that all users, ranging from administrative personnel to healthcare providers, have the necessary skills to effectively use the system. ### Maintenance Continual costs encompass system upgrades, technical assistance, and problem-solving. Consistent maintenance is essential for ensuring optimal performance and security of the system, which contributes to the overall expenses of implementing EHR/EMR in the long run. ### User Error Although EHR/EMR systems offer benefits, they can also pose usability obstacles that impact their effectiveness and user contentment. Certain EHR/EMR systems possess interfaces that are challenging to navigate, resulting in inefficiencies and user dissatisfaction. Elaborate systems can overpower healthcare providers, diminishing the amount of time allocated for patient care. The process of entering data into EHR/EMR systems can be time-consuming due to its extensive nature. This requirement frequently diminishes the amount of time healthcare providers can allocate to patients, potentially affecting the quality of care. Numerous EHR/EMR systems are developed with a standardized approach, which may not adequately cater to the specific requirements of all medical practices. Adapting these systems to match the distinct workflows and needs of various healthcare settings can be difficult and may necessitate extra resources. ### Data Safety Safeguarding patient information within EHR/EMR systems is of utmost importance, however, it is necessary to address and mitigate various risks: Data breaches pose a significant concern due to the potential for unauthorized access to sensitive patient data. Data breaches can lead to the disclosure of personal health information, which can have legal and financial consequences for healthcare organizations. #### Compliance It is crucial to ensure that EHR/EMR systems adhere to regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). Failure to comply can lead to significant financial penalties and harm the organization\'s reputation. EHR/EMR systems are prone to cyberattacks and system failures due to technical vulnerabilities. To defend against these dangers, it is necessary to implement strong cybersecurity protocols and consistently update systems to fix any weaknesses. The Health Information Technology for Economic and Clinical Health (HITECH) Act, passed in 2009, seeks to encourage the adoption and meaningful use of health information technology in healthcare. HITECH compliance entails ensuring that healthcare providers use certified Electronic Health Record (EHR) systems effectively in order to improve patient care. This includes meeting specific requirements for the secure exchange of health information, safeguarding patient privacy, and improving clinical outcomes. HITECH also incentivizes providers with financial rewards for achieving meaningful use and imposes penalties for noncompliance, promoting the widespread and standardized use of EHR systems in the healthcare industry. Comprehending these obstacles is essential for healthcare students as they get ready to interact with EHR/EMR systems. To effectively overcome these limitations, healthcare organizations can optimize the advantages of EHR/EMR systems while minimizing their disadvantages. Legal and Ethical Considerations in the Use of Electronic Health Records (EHR) and Electronic Medical Records (EMR) ------------------------------------------------------------------------------------------------------------------- The implementation of EHR/EMR systems in healthcare introduces various legal and ethical factors that are crucial for upholding patient confidence and adhering to regulatory requirements. ### Data Protection and Secrecy Preserving patient privacy and confidentiality is of utmost importance when utilizing EHR/EMR systems. Several crucial factors guarantee the protection of sensitive patient information: #### HIPAA Compliance The Health Insurance Portability and Accountability Act (HIPAA) establishes the benchmark for safeguarding confidential patient information. EHR/EMR systems are required to adhere to HIPAA regulations, which guarantee the protection of patient information from unauthorized access and breaches. Implementing strict access controls is essential to restrict the individuals who have permission to view and modify patient information. Role-based access control guarantees that only authorized individuals, such as healthcare providers who are directly engaged in a patient\'s treatment, are able to access particular patient information. This measure serves to mitigate unauthorized entry and potential abuse of data. Data encryption is crucial for safeguarding data during transmission (while it is being transferred across networks) and when it is stored (at rest). Encryption guarantees that in the event of data interception or unauthorized access, the information will remain indecipherable and protected. ### Standards for Documentation Thorough documentation in EHR/EMR systems is crucial for both legal and clinical reasons. Following documentation standards guarantees the reliability and usefulness of patient records. #### Precision Every entry in the EHR/EMR system must be precise and current. Precise documentation guarantees that healthcare providers possess dependable information to foundation their clinical judgments on, thereby augmenting patient care. Promptly recording information after patient encounters is crucial for timeliness. Ensuring timely documentation guarantees that the patient\'s medical record remains up-to-date, accurately reflecting recent treatments, diagnoses, and other pertinent information. #### Completeness Thorough documentation encompasses all pertinent information regarding a patient\'s medical condition, treatment strategies, and engagements with healthcare professionals. This facilitates a comprehensive understanding of the patient\'s complete medical background, thereby assisting in the seamless provision of healthcare and ensuring legal responsibility. Ethical Utilization of Electronic Health Records (EHR) and Electronic Medical Records (EMR) Healthcare providers are required to utilize EHR/EMR systems in an ethical manner in order to preserve patient trust and adhere to professional standards. Ethical use encompasses various fundamental principles: #### Patient Consent It is crucial to educate patients regarding the utilization of their information and acquire their explicit permission. Patients should possess knowledge of their entitlements concerning their health information and the manner in which it will be disseminated and utilized within the healthcare system. #### Transparency Healthcare providers are obligated to be forthright with patients regarding any data breaches or concerns that could impact their privacy. Transparency promotes confidence and guarantees that patients are completely aware of the condition of their personal health information. Professional integrity dictates that EHR/EMR systems should be utilized to improve patient care, rather than for personal benefit or convenience. Healthcare providers should give priority to patient well-being and responsibly utilize the system to enhance clinical results and uphold ethical standards. Medical assistant students will gain a better ability to navigate the complexities of EHR/EMR systems in their future careers by comprehending these legal and ethical considerations. They will possess the necessary skills and knowledge to maintain high levels of privacy, accuracy, and integrity in handling digital health records. This will ensure that the utilization of such records has a beneficial impact on patient care and the healthcare system in its entirety. Optimal Strategies for EHR/EMR Utilization ------------------------------------------ In order to optimize the efficacy and efficiency of EHR/EMR systems, healthcare providers should strictly adhere to the most effective methods of data entry, seamless integration of workflows, and effective patient interaction. ### Data Entry and Documentation Precise and prompt data entry is crucial for the efficient utilization of EHR/EMR systems. Adhering to established guidelines in this field guarantees that patient records are dependable and thorough: #### Consistency It is important that all data entries adhere to a standardized format. The consistency of patient records facilitates efficient navigation and comprehension, enabling healthcare providers to promptly locate the necessary information. Standardization decreases the amount of variation and enhances the quality of documentation. #### Elaboration Clinical notes should be thorough and inclusive in order to encompass the entirety of patient interactions. This entails recording patient symptoms, diagnoses, treatment strategies, and any subsequent guidelines. Comprehensive documentation offers a thorough overview of the patient\'s well-being and enhances the process of making informed clinical judgments. #### Assessment It is imperative to consistently evaluate and revise patient records to guarantee their currency and precision. Regular evaluations facilitate the detection and rectification of any inaccuracies or exclusions, ensuring that the patient\'s health information remains current and dependable for subsequent medical attention. ### Integration of Workflows In order for EHR/EMR systems to be efficient, they need to seamlessly incorporate themselves into the current clinical workflows. Integration can be accomplished using various strategies: #### Custom Templates Utilizing templates that align with the specific requirements of the practice can optimize documentation procedures. Custom templates facilitate the standardization of data entry and ensure the efficient capture of all required information. #### Automation Utilizing automated functions like reminders, alerts, and order sets can greatly enhance efficiency. Automated reminders facilitate the timely provision of follow-up care to patients, while alerts can promptly inform healthcare providers of crucial information or required actions, thereby improving patient safety. Interoperability is essential for comprehensive patient care as it ensures that the EHR/EMR system can effectively communicate with other systems, including laboratories and pharmacies. Interoperability facilitates the smooth and efficient sharing of information, thereby minimizing the requirement for redundant tests and enhancing collaboration among diverse healthcare providers. ### Interacting with Patients Optimal utilization of EHR/EMR systems during patient interactions necessitates actively involving patients and safeguarding their confidentiality. #### Engagement By elucidating the advantages of EHR/EMR systems to patients and actively involving them in the process of documenting their medical information, their level of engagement in their own healthcare can be significantly enhanced. Patients who possess a clear comprehension of how their information is utilized are more inclined to experience a sense of involvement and actively participate in the management of their health. #### Transparency The act of sharing pertinent sections of the Electronic Health Record (EHR) or Electronic Medical Record (EMR) with patients, such as laboratory results or treatment plans, fosters transparency and builds trust. This practice facilitates patients\' comprehension of their health conditions and the underlying reasoning behind their treatment plans, thereby promoting enhanced communication and collaboration. Preserving patient privacy is crucial when utilizing EHR/EMR systems. It is advisable to place screens in a location where they are not visible to the general public, and healthcare professionals should ensure they log out of computer systems when they are not actively using them. These measures serve to safeguard confidential patient data and adhere to privacy regulations. Healthcare providers can optimize the effectiveness of EHR/EMR systems by following these best practices. This will ensure that the systems adequately support high-quality patient care and streamline clinical workflows. In order to be adequately prepared for their future careers, medical assistant students should acquaint themselves with these practices, which involve the management and utilization of EHR/EMR systems. Operate an EMR/EHR System ------------------------- Implement updates in an EMR/EHR. Although EMR and EHR are frequently used interchangeably, they differ. An EMR is an electronic record of a patient\'s medical history. It is used by a single organization. An EHR contains the patient\'s EMR, but it can be used by more than one health care organization. EHRs are intended to reach beyond the health organization that initially collects and compiles the information. They are designed to share information with other health-care providers, such as laboratories and specialists, so they include data from all clinicians involved in the patient\'s care. Health care providers and organizations must submit statistics on communicable and infectious diseases (HIV/AIDS, tuberculosis, and sexually transmitted infections) to local and state government agencies. These agencies will also collect and report this information to the federal government and other agencies, including the CDC. Since health care providers are required to report cases of births, deaths, and communicable diseases, this information can be collected and used to create vital records or statistics for state and local governments. Vital records are useful because they provide detailed information about the incidence (new cases) and prevalence (existing cases) that can be used to make public health decisions. Helmet laws were enacted in response to an increase in the number of deaths and head injuries caused by motorcycle accidents. Federal and state governments and agencies frequently use health information in medical records to make health-care decisions. Their decisions may be influenced by new and existing health-care policies and legislation, as well as other factors. Health information can be used to determine which type of coverage Medicare or Medicaid patients receive. For example, the Centers for Medicare & Medicaid Services, the federal agency in charge of these programs, reviews the history of care provided to its beneficiaries and determines the cost and quality of care before deciding on reimbursements and enacting legislation. These decisions, as well as the legislation, will have an impact on future Medicare and Medicaid service coverage, reimbursement, and availability. Enter Orders Using a CPOE ------------------------- As a result of EHR adoption, many state and federal laws were enacted to require health care providers to use a computerized provider order entry (CPOE) system, thereby making health care delivery safer and more efficient. CPOE is an electronic process that allows a health care provider to enter medical orders into a system rather than using traditional methods such as paper, verbal, telephone, or fax. Once you\'ve electronically entered an order for lab tests, prescription medications, radiology tests, or referrals, the CPOE system communicates with other EHR components, such as the pharmacy or laboratory system, to process it. Reducing the use of written orders reduced medical and medication errors by avoiding transcription errors, misplaced decimals, and illegible handwriting. The following provides an overview of the advantages of a CPOE system: - Reducing human error - Improving care delivery time - Improving order accuracy - Reducing order confirmation and turnaround time - Improving clinical decision support at the point of care - Increasing access to critical information - Improving communication among healthcare providers, professionals, and patients By allowing health care providers to submit orders electronically, CPOE can help get medication, laboratory, and radiology orders to pharmacies, laboratories, and radiology facilities more quickly, saving time and increasing efficiency. CPOE can improve workflow processes by eliminating lost orders and ambiguities caused by illegible handwriting, automatically generating related orders, monitoring for duplicate orders, and reducing order processing time. It can also help to reduce errors by requiring health care providers to submit orders that are standardized, legible, and complete. A CPOE is often paired with or includes a clinical decision support system (CDSS). A CDSS contributes to patient care by improving medical decisions through targeted clinical knowledge, patient information, and other health information. For example, a CDSS can automatically check for medication interactions, allergies, and errors in medication dosage and frequency. More advanced CDSSs can prevent prescriptions from being ordered at excessively high doses, alert when a medication needs to be prescribed for or after a procedure, prevent overprescribing due to abuse, and even assist in prescribing the appropriate treatment. A CPOE system can be used on its own, but most EHR software now includes one, allowing health care providers and professionals to enter patient data electronically into text boxes and drop-down menus. The integration of CPOE with an EHR can also boost clinical productivity. When combined with an EHR system, a CPOE can flag orders that require pre-approval, thereby reducing denied insurance claims. Many CPOE systems follow a six-step process. 1. A provider logs into an EMR. 2. After logging in, the provider can view a list of patients on the screen. 3. The system allows providers to order prescriptions, lab work, and medical scans for specific patients. 4. The system validates the order based on the patient\'s medical history, insurance plan, and other stored data. 5. If no errors are found, the order will be sent to a product or service provider, usually a pharmacy or laboratory. 6. The order is added to the patient\'s permanent records, facilitating future reviews, orders, and access by care providers. The use of CPOE allows for electronic order entry rather than paper entry, which results in faster turnaround times for patients and fewer life-threatening errors. Although medical assistants are not authorized to submit orders, you may be required to enter the order\'s information before requesting authorization from the health care provider. Telehealth Technologies ----------------------- Telehealth is delivered and used in a variety of ways, including electronic submissions and live video calls. Electronic submissions enable providers and other allied health personnel to exchange patient health information, diagnostic results, and other patient-related information by sending and receiving data electronically. This has become an excellent way for primary care physicians, specialists, and radiologists to communicate with patients regardless of their physical location. Live video enables the provider and patient to communicate in real time using two-way interactions. There are numerous benefits to using live video, including transportation issues, financial constraints, or poor health. Technology-Based Methods for Providing Health Care and Information ------------------------------------------------------------------ Telehealth refers to health care delivered virtually, most commonly via video call. Telehealth has grown in popularity to protect patients from communicable diseases, provide convenience, and enable patients in rural areas to access specialty care that was previously unavailable. Telehealth can be a great way for patients and providers to review many aspects of care, but it does have limitations. Medical assistants may have multiple responsibilities during virtual visits. Scheduling virtual visits may take longer because the MA must collect or confirm the patient\'s email address, ensure the link is sent, and review instructions. Some offices provide patients with a test visit in which an administrator or MA logs into the link to ensure the patient has access when it is time for their appointment. Medical assistants may also participate in the actual visit, just as they would during a regular office visit. This can include taking a history, verifying medication and pharmacy information, creating an agenda, and communicating with the patient about the next steps, such as referral or diagnostic testing coordination. Telehealth can be useful for following up on medication adjustments, reviewing chronic conditions, providing patient education, evaluating minor rashes and skin concerns, following up on new medical equipment (e.g., CPAP machine), and discussing lab results. In-person Evaluation Requirements include diagnostic testing (e.g., imaging or lab work), new pain symptoms, and a physical examination. Conduct Telehealth or Virtual Screenings ---------------------------------------- Telehealth has a broad definition. It is a type of service in which health care providers use video calling and other technologies to provide patient care in a remote location, such as the patient\'s home, rather than a medical facility. Although the terms are frequently used interchangeably, telehealth and telemedicine are distinct types of online health care services. Telemedicine specifically refers to online health care provider visits and remote clinical services, whereas telehealth encompasses a broader range of health-related education services such as diabetes management or nutrition courses, as well as healthcare training. Telehealth can also refer to remote nonclinical services like provider training, administrative meetings, and continuing medical education. Telehealth insurance coverage varies greatly by state, with differences in how the term is defined and reimbursed. For example, some states may only reimburse for specific telehealth services. Telehealth is most similar to a regular visit to a health care provider, allowing for two-way communication. The provider can check on patients, inquire about their health, and then recommend an appropriate treatment. Such a visit requires interoperability across multiple devices, such as a webcam, a phone, a computer audio system, or chat capabilities. Telehealth has grown in popularity over the last decade as a result of patient and provider willingness to use it, regulatory changes that allow for greater access and reimbursement, and the need for health care during pandemics. Telehealth may be used to provide the following types of care: - General health care, such as wellness visits. - Prescriptions for routine medicine. - Dermatology (skin care) - Eye exams - Nutrition counseling - Mental health counseling - Urgent care for sinusitis, UTIs, and common rashes. One of the most common types of telehealth is virtual visits. Patients can contact a health care provider or a nurse via online or phone chat. Virtual visits can treat a variety of conditions, including migraines, skin conditions, diabetes, depression, anxiety, colds, coughs, and COVID-19. Furthermore, health care providers may use virtual consultations, in which one health care provider can seek advice from specialists in other locations if they have questions about a diagnosis or treatment options. The health care provider can send exam notes, history, lab results, x-rays, and other images to the specialist for review. Telehealth includes remote patient monitoring, where health care providers can receive information from a patient\'s wearable device, such as heart rate and blood glucose levels. Some surgical procedures can be performed remotely from another location using robotic technology. A health care provider may also send a patient an online video on how to properly use an inhaler. Modifications for Telehealth and Virtual Health Care ---------------------------------------------------- In many cases, health care providers\' interactions with patients via telehealth are just as effective as traditional face-to-face visits in a medical practice. The patient and health care team must prepare before and after their medical visit. The use of technology by health care providers and professionals has no effect on their standard of practice, ethics, or scope of practice, nor on the laws that protect patients and health care providers. Before the visit, ask the patient to send you information or forms to fill out online and return. You may need to send instructions and information about technology requirements for any telehealth services, such as a virtual visit. The instructions should explain how the patient should sign on to the video chat for the visit, as well as how to use the microphone, camera, and text chat. To participate in the virtual visit, the patient must have access to an internet-connected smartphone, tablet, or computer. In addition, the patient should ensure that any necessary software or applications are updated or installed. Both the patient and the health care provider should find a comfortable, quiet, and private place to sit during the visit. With advancements in technology, some medical practices can now perform remote physical examinations by viewing images and hearing sounds. As a result, health care providers can assess and treat a wide range of diseases and conditions, including cardiac and respiratory illnesses, by listening to digital heart and lung sounds live and transmitting the data via a video conferencing system. Video scopes can also be used by healthcare providers to perform eye, ear, nose, and throat examinations. In some cases, patients may self-report vital signs and other biometric data, such as their height, weight, and blood pressure. Many patients with hypertension, obesity, and diabetes may be skilled at measuring glucose and blood pressure, and the health care provider may be comfortable with the patient\'s self-report. The medical assistant should remind patients to have their measurements ready before the appointment. Patient Education through Telehealth or Virtual Visit Systems and Processes --------------------------------------------------------------------------- Telehealth and virtual appointments are examples of technology-enabled health care and education delivery. During these encounters, the patient and provider can communicate and sometimes see each other via an electronic device like a tablet, laptop, or cell phone. This can be a great way for providers to educate patients without having them come in for an appointment. Telehealth has enabled rural areas to obtain previously unavailable treatments. An MA assisting with a telehealth appointment may be responsible for the following tasks. - Assisting with technical issues during telehealth encounters. - Documenting pertinent information in the patient\'s medical record - Providing provider-approved patient education - Scheduling follow-up and referral appointments - Answering any questions within their scope of practice regarding the patient\'s treatment plan ### Educational Delivery Methods, Instructional Techniques, and Learning Styles Learning is the acquisition of new knowledge or skills through instruction or experience. Patient education aims to embed information in the patient\'s long-term memory, but not everything will be picked up at once. Understand the various learning styles and decide which is best for the patient. #### Learning Styles There are three main ways for people to obtain new information. Inquire about the patient\'s preferred learning method. - Auditory learning involves hearing information. This can be accomplished by giving information verbally while the patient listens. One example is to read follow-up instructions to the patient while they listen to the MA. - Kinesthetic learning is characterized by physical movement or task performance. This method of learning entails both observing and performing the action. A return demonstration or an anatomical model that the patient can touch is the most effective way to demonstrate the skill required. A common example is showing how to use a glucometer to check blood sugar levels. - Visual learning involves reading information and viewing diagrams/graphics. ### Educational Delivery Methods and Instructional Techniques There are numerous ways to educate patients. Provide a quiet environment for the teaching session, as distractions are harmful to learning. Speak at an appropriate pace, not too quickly or slowly, and maintain eye contact with the patient. Therapeutic communication enables the patient to feel at ease and actively participate in the learning process. Give the patient written information to take home. Written information should be in layman\'s terms, without medical jargon, and at the patient\'s appropriate reading and comprehension level. Understanding the patient\'s learning style aids in determining the most effective methods of providing information. Provide visual materials for those who learn by seeing, such as DVDs or approved online videos. Provide kinesthetic learning materials so that the patient can practice the skill. Active involvement allows the patient to take ownership of the skill they are learning. Demonstration followed by a return demonstration and repetition of the skill will help with information retention and allow the patient to perfect the skill while receiving positive feedback. Understanding the patient\'s preferences and learning style can help determine which type of patient education and coaching will be most effective. Regardless of the patient\'s learning style or delivery method, it is critical to solicit feedback. This is critical for determining the effectiveness of the teaching session. Restating, repeating, and rephrasing the material is a way to assess the patient\'s understanding. Positive reinforcement reduces fear or resistance to learning information that is intimidating or overwhelming.