HIMT 204 Lecture 3: Electronic Health Information & Record System Overview PDF

College of Applied Medical Sciences in Dammam Academic Year 2024-2025 Health Information (HIMT 204) Electronic Health Information & Record System Overview Lec tu re 3...

College of Applied Medical Sciences in Dammam Academic Year 2024-2025 Health Information (HIMT 204) Electronic Health Information & Record System Overview Lec tu re 3 Nouf Alassaf  Learning Objectives At the end of this session, you should be able to: State the definition and history of electronic health records (EHRs). Describe the limitations of paper and hybrid medical records. Differentiate between EHR used terms. List the key components of an EHR. Health Record Overview  Health Record: Definition - “It is a confidential compilation of pertinent facts of an individual's health history, including all past and present medical conditions, illnesses and treatments. The information documented in the health record is created by all healthcare professionals providing care and is used for continuity of care” (Canadian Health Information Management Association​, n.d.)  Health Record: Content - Patient identification and demographics - Clinical documentation o patient health history o orders o results o assessments o medications - Billing and revenue cycle information  Health Record: Uses - Primary purposes are: 1. Documentation o facilitates patient care o continuity of care 2. Communication o integrates data from multiple sources and caregivers 3. Finance o coding (justify reimbursement to third party) o billing  Health Record: Uses (Cont.) - Other purposes are: o Quality assurance for accreditation requirements o Legal purpose historical record of what was done medicolegal cases o Preventive care immunizations o Research prospective retrospective  Health Record: Evaluation - Representing the patient’s true state o Completeness Proportion of observations that are recorded o Correctness Proportion of recorded observations that are correct - These two things drive decisions in configuration!  Health Record: Types 1. Paper-based Medical Record 2. Hybrid Medical Record 3. Electronic Health Record  Health Record: Types (Cont.) 1. Paper-Based Medical Record - A paper-based record involves documenting information related to the patient’s healthcare in a physical manner such as paper and films and storing it in a physical storage to be retrieved when needed  Health Record: Types (Cont.) 1. Paper-Based Medical Record - Advantages o Low initial cost paper, printer, folders, space to store (cabinets) no need for training programs o Ease of use minimal skills to review and complete o Easy to customize the forms no need for technical skills o No need for Internet access  Health Record: Types (Cont.) 1. Paper-based Medical Record - Disadvantages o Legibility limit to understand & use the written information hard to shared & stored o Passive cannot be analyzed with computerized tools no decision support Outpatient paper-based patient encounter form  Health Record: Types (Cont.) 1. Paper-based Medical Record - Disadvantages (Cont). o Lost or being used elsewhere where to record if chart is missing ("shadow chart”) o Poorly organized data missing fragmented ▪ 1 patient: multiple volumes of records o Only one view redundancy difficult to research  Health Record: Types (Cont.) 2. Hybrid Medical Record - It is a combination of electronic and paper health record o electronic record: the laboratory and radiology results, and scanned documents o paper record: the progress notes, nurses’ notes, and other documents - Most health records are hybrid  Health Record: Types (Cont.) 2. Hybrid Medical Record - Advantages o It allows access to records by multiple healthcare professionals simultaneously o If the system fails (server breakdown), health professionals can easily shift to the paper-based o Illegible documents can be audit and corrected when scanned into a medical record o Coders have access to electronic system when paper records is busy o Easier than paper-based to accomplish a request for releasing information  Health Record: Types (Cont.) 2. Hybrid Medical Record - Disadvantages o Need more time and staff to administer o More avenues for data breach o Locating where the record is stored  Health Record: Types (Cont.) 3. Electronic Health Record Electronic Health Record (EHR) EHR: Definition  EHR: Definition (Cont.) - “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one healthcare organization” - Previousely, it referred to as: o Clinical Information System “CIS” o Health Information System “HIS” EHR  EHR: Terms Terms often used interchangeably (EHR, EMR and PHR) Electronic Medical Record (EMR) - “An electronic record of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one healthcare EHR organization” EMR  EHR: Terms (Cont.) Terms often used interchangeably (EHR, EMR and PHR) Personal Health Record (PHR) - “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while EHR being managed, shared and controlled by the individual” - More in lecture 8 PHR EMR  EHR: History Increased using IOM report computers to sort o 44,000 - 98,000 patient records annual Americans mortality from Hospitals need VistA initiated by U.S. medical errors records for Department of Veterans o EHRs as a solution accreditation Affairs Considered a Wakeup Call 1910 1940s 1960s 1970s 1980s 1990s 2000s Flexner report Research – Certifying Problem-Oriented Medical Record standardization EHR Advocated needed maintaining Dr. Larry Weed Increasing patient VistA became commercial records open source systems The most successful attempts Limitations!  EHR: Structure The following are components found in most commercial EHRs available today POC EMAR CPOE CDSS Robotics Copyright © 2008, Margret\A Consulting, LLC.  EHR: Structure (Cont.) 1. EHR Foundation - It is administrative-related component o Registration-Admission, Discharge, Transfer (R-ADT) for outpatient, Practice Management System (PMS) purpose: register patient, record demographic and insurance information, schedule appointment o Patient Financial Service (PFS) billing system purpose: receive charges and submit claims  EHR: Structure (Cont.) 2. Source Systems - A standalone system that capture data, could be: ICU o Ancillary, or departmental system ex: Lab, radiology, inpatient pharmacy purpose: manage the department, general clinical results and charges o Specialty clinical system ex: ICU, cardiology, emergency medicine serve patients with specific disease states or level of nursing care required Robotics o Smart peripherals Smart Pump ex: smart infusion pumps, monitoring equipment  EHR: Structure (Cont.) 2. Source Systems - Laboratory information system o A software with features that support laboratory's operations such as: receives order generates specimen collections lists prints labels connects to auto- analyzers tracks quality controls schedules staff inventories supplies Example of laboratory information system  EHR: Structure (Cont.) 3. Core Clinical Applications - Essential components for EHR POC - More in lecture 4 EMAR CPOE CDSS  EHR: Structure (Cont.) 4. Supporting Infrastructure - Aids to integrating data from multiple sources - Includes 1. Storage - to archive data 2. Knowledge sources – to make information available from external sources o ex: drug knowledge database that describe the active ingredients of drugs and what their impacts 3. Data warehouse and data mining - to analyze patient data and provide new knowledge  EHR: Structure (Cont.) 5. Presentation Layer - The part that helps data entry and retrieval - Utilizes various input devices (human- computer interfaces), such as: o personal computers, o notebooks, o laptops, o tablets, o smart phones, o voice/speech recognition, o handwriting recognition  EHR: Structure (Cont.) 6. Connectivity - Supports the capture and integration of data - Requires network hardware and software that enable transmission of data across LAN and WAN - Result o seamless exchange of health information across disparate organizations  EHR: Structure (Cont.) - The results of implementing the technical components of the EHR structure: o High quality o Low cost o Easy access  Summary - A health record is patient’s account that contains information regarding presenting symptoms, with comments from providers - It is mainly used for documentation, communication, and justifying reimbursement - To be useful, it must be complete and accurate as reference in continuing patient care - It can be paper-based, hybrid or electronic - EHR is not just automating the paper documents in the chart - POMR method was the most successful attempts in collection of patient records - IOM report was the wakeup call to support EHR - EHR has different features based on its vendor - EHR differ than EMR in the interoperability standards  References Amatayakul, M. (2006). Electronic health records: A Practical guide for professionals and organizations. (4th ed.) American Health Information Management Association. Canadian Health Information Management Association​. (n.d.). What is a health record? http://www.himconnect.ca/patients/commonly-asked- questions/what-is-a-health-record Dimick, C. (2008). Record limbo: Hybrid systems add burden and risk to data reporting. American Health Information Management Association. 79(11). 28-32. EMR Finder. (2022). EPIC EMR software. https://www.emrfinder.com/epic- ehr-software/ Fond du Lac County. (n.d.). Medical records. https://www.fdlco.wi.gov/departments/departments-a-e/community- programs/services-and-programs/medical-records  References (Cont.) Garrett, P. & Seidman, J. (2011). EMR vs EHR – What is the difference? https://www.healthit.gov/buzz-blog/electronic-health-and-medical- records/emr-vs-ehr-difference Hebda, T., Hunter, K. & Czar, P. (2024). Handbook of informatics for nurses and healthcare professionals. (7th ed.). Pearson. Chapter 7 Hoyt, R. E. &Yoshihashi, A. K. (2018). Health informatics: Practical guide for healthcare and information technology professionals. (7th ed.). Lulu.com. Kohn, L. T., & Corrigan, J. M. (1999). To err is human: Building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Pepper, J. (2018). The electronic health record for the physician’s office: For Simchart for the medical office. (2nd ed.). Elsevier. THANK YOU