Introduction to Health Information Systems (HIS) PDF

Computer Skills Introduction to Health Information Systems (HIS) EMR vs HER vs PHR and e-Prescribing Definitions, Benefits and Differences 1 Content o Introduction o Data, Information, and knowledge o The characteristics of valuable inf...

Computer Skills Introduction to Health Information Systems (HIS) EMR vs HER vs PHR and e-Prescribing Definitions, Benefits and Differences 1 Content o Introduction o Data, Information, and knowledge o The characteristics of valuable information o Health Information Systems (HIS) basics o EMR vs HER vs PHR and e-Prescribing: (definitions, benefits and differences) Electronic medical records (EMR) Electronic Health Records (EHR) Personal Health Records (PHR) Electronic prescribing (e-Prescribing) o Health Information Exchange (HIE) o HIS security 2 Lesson Outcomes 1. Explain the Electronic Medical Records (EMR). 2. Explain the Electronic Health Records (EHR). 3. Differentiate between EMR and EHR. 4. Explain the Personal Health Records (PHR). 5. Explain the Electronic Prescribing (e-Prescribing). 3 EMR, EHR, PHR, and e-Prescribing o HIS may include the following systems to computerize health records: 1. Electronic Medical Records (EMR) 2. Electronic Health Records (EHR) 3. Personal Health Records (PHR) 4. Electronic Prescribing (e-Prescribing) Before defining the previous terms, we need to differentiate between two important terms: medical records and health records. Medical records were for use by clinicians mostly for diagnosis and treatment. Health records relates to “The condition of being sound in body, mind, or spirit; especially freedom from physical disease or pain the general condition of the body.” 4 Electronic Medical Records (EMR) o EMR are digital versions of the paper charts in clinician offices, clinics, and hospitals. o EMR contain notes and information collected by and for the clinicians in that office, clinic, or hospital and are mostly used by providers for diagnosis and treatment. 5 Electronic Medical Records (EMR) o The benefits of EMR are: 1. Enable providers to track data over time, 2. Identify patients for preventive visits and screenings, 3. Monitor patients, and 4. Improve health care quality. o The information stored in EMR is not usually shared with providers outside of an organization. o A patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. 6 Sample of EMR 7 Electronic Health Records (EHR) o EHR are digital records of health information. o HER include: o Past medical history o Vital signs o Progress notes o Diagnoses o Medications o Immunization dates o Allergies o Lab data o Imaging reports o Can also contain other relevant information, such as insurance information, and demographic data. 8 Electronic Health Records (EHR) o EHR are built to share information with other health care providers and organizations such as: o Laboratories o Specialists o Medical imaging facilities o Pharmacies o Emergency facilities, and o School and workplace clinics. They contain information from all clinicians involved in a patient’s care. 9 Sample of EHR 10 Electronic Health Records (EHR) o The benefits of EHR are: 1. Improve patient care 2. Increase patient participation 3. Improved care coordination 4. Improved diagnostics & patient outcomes 5. Practice efficiencies and cost savings 11 EMR vs EHR EHR EMR A digital record of health information A digital version of patient chart Allows access to tools that providers Is mainly used by providers for diagnosis can use for decision making and treatment Allows a patient’s medical information to Patient record cannot easily be sent be accessed from different places outside the practice Simplified sharing of updated, real-time Not designed to be shared outside the information individual practice 12 Personal Health Records (PHR) o PHR are electronic medical charts that contain medical data and information about a patient that are designed to be set up, accessed, and managed by patients themselves. o Patients can use PHR to maintain and manage their health information in a private, secure, and confidential environment. o PHR include information from a variety of sources including: o Clinicians o Home monitoring devices, and o Patients themselves. 13 Sample of PHR 14 Personal Health Records (PHR) oThe benefits of PHR are: 1. PHR grant patients access to a wide range of health information sources, best medical practices, and health knowledge. 2. All of an individual’s medical records are stored in one place instead of paper- based files in various doctors’ offices. 3. PHR offer patients the opportunity to submit their data to their physicians → This helps clinicians make better treatment decisions. 15 Personal Health Records (PHR) oThe benefits of PHR are: 4. PHR help in analyzing patient’s health profile for analysis drug interaction, current best medical practices, gaps in current medical care plans, and identification of medical errors. 5. PHR help in tracking patient illnesses. 6. PHR help in reducing the time consumed by face-to-face meetings and telephone communication. 7. PHR can quickly provide critical information to proper diagnosis or treatment. It also helps in making appointments, etc. 16 The difference between PHR, EHR, and EMR EMR EHR PHR Medical specialists in one Doctors across hospitals, labs, End-user Patients department pharmacies, patients Include patient's medical history that is entered by patients Medical history, prescriptions, Electronic records of health- Type of themselves, as well as data from current patient's health related information on an information other sources such as conditions individual pharmacies, labs, and healthcare providers Can be created, gathered, Can be created, managed, and managed, and consulted by Information consulted by authorized clinicians Can be created, gathered, and authorized clinicians and staff access and staff across more than one managed by patients within a single healthcare healthcare organization organization 17 Electronic prescribing (e-Prescribing) o Prescription is securely transmitted to pharmacies electronically using a special software program over the Internet / Intranet. o When a pharmacy receives a request, it can begin filling the medication right away. o The benefits of e-Prescribing are: 1. Improves health care quality and patient safety by reducing medication errors and checking for drug interactions. 2. E-Prescribing is more convenient, cheaper, and safer for doctors, pharmacies, and patients. 18 Electronic prescribing 19 20  Computer Skills Introduction to Health Information Systems (HIS) Health Information Exchange (HIE) 1 Content o Introduction o Data, Information, and knowledge o The characteristics of valuable information o Health Information Systems (HIS) basics o EMR vs HER vs PHR and e-Prescribing: (definitions, benefits and differences) Electronic medical records (EMR) Electronic Health Records (EHR) Personal Health Records (PHR) Electronic prescribing (e-Prescribing) o Health Information Exchange (HIE) o HIS Security 2 Lesson Outcomes At the end of this lesson you should be able to: 1. Explain the process of accessing and sharing medical information across HIS. 2. Describe the three forms of exchanging: Directed Exchange, Query- based Exchange, and Consumer Mediated Exchange. 3. Evaluate the form of exchanges while basing on real life examples. 3 Health Information Exchange (HIE) o Electronic Health Information Exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically improving: The The The The cost of speed quality safety patient care 4 Health Information Exchange (HIE) o Appropriate, timely sharing of vital patient information can better inform decision making at the point of care and allow providers to: Standardization of Avoid readmissions Avoid medication patient data errors Decrease duplicate Improve diagnoses testing 5 Health Information Exchange (HIE) Forms of exchange o There are currently three key forms of HIE: 1. Directed exchange: ability to send and receive secure information electronically between care providers. 2. Query-based exchange: ability for providers to find and/or request information on a patient from other providers. 3. Consumer mediated exchange: ability for patients to aggregate and control the use of their health information among providers. The foundation of standards, policies and technology required to initiate all three forms of HIE are complete, tested, and available today. 6 Health Information Exchange (HIE) Forms of exchange 1. Directed exchange o Directed exchange is used by providers to easily and securely send patient information such as: Laboratory orders and results Patient referrals, or Discharge summaries directly to another health care professional. o This information is sent over the Internet in an encrypted, secure, and reliable way amongst health care professionals who already know and trust each other and is commonly compared to sending a secured email. o This form of information exchange enables coordinated care, benefitting both providers and patients. 7 Health Information Exchange (HIE) Forms of exchange o Example of directed exchange: A primary care provider can directly send electronic care summaries that include medications, problems, and lab results to a specialist when referring their patients. This information helps to inform the visit and prevents the duplication of tests, redundant collection of information from the patient, wasted visits, and medication errors. 8 Health Information Exchange (HIE) Forms of exchange 2. Query-based exchange o Query-based exchange is used by providers to search and discover accessible clinical sources on a patient. o This type of exchange is often used when delivering unplanned care. o Examples: Emergency room physicians who can utilize query-based exchange to access patient information such as medications, recent radiology images, and problem lists might adjust treatment plans to avoid adverse medication reactions or duplicative testing. If a pregnant patient goes to the hospital, query-based exchange can assist a provider in obtaining her pregnancy care record, allowing them to make safer decisions about the care of the patient and her unborn baby. 9 Health Information Exchange (HIE) Forms of exchange 3. Consumer-Mediated Exchange o Consumer-mediated exchange provides patients with access to their health information, allowing them to manage their health care online in a similar fashion to how they might manage their finances through online banking. o When in control of their own health information, patients can actively participate in their care coordination by: Providing other providers with their health information. Identifying and correcting wrong or missing health information. Identifying and correcting incorrect billing information. Tracking and monitoring their own health. 10 Health Information Exchange (HIE) Benefits of HIE o Many benefits exist with information exchange regardless of the means of which is it transferred. o However, the value of electronically exchanging is the standardization of data. o Once standardized, the data transferred can seamlessly integrate into the recipients' Electronic Health Records (EHR), further improving patient care. o Example: If laboratory results are received electronically and incorporated into a provider’s HER a list of patients with diabetes can be generated. The provider can then determine which of these patients have uncontrolled blood sugar and schedule necessary follow-up appointments. 11 Health Information Exchange (HIE) Benefits of HIE o HIE benefits include: HIE reduces duplicative treatments and avoids costly mistakes. Improves quality and safety of patient care by reducing medication and medical errors. Stimulates patient’s involvement in their own health care. Increases efficiency by eliminating unnecessary paperwork. Provides caregivers with clinical decision support tools for more effective care and treatment. Improves public health reporting and monitoring. Provides a basic level of interoperability among electronic health records (EHRs) Reduces health related costs. 12 13