Medical assisting Administrative and clinical procedures (5e) Chapter 12 Electronic health records

CHAPTER

12
Electronic Health
Records


12-2

Learning Outcomes (cont.)
12.1 List four medical mistakes that will be greatly
decreased through the use of EHR.
12.2 Differentiate among electronic medical
records, electronic health records, and personal
health records
12.3 Contrast the advantages and disadvantages
of electronic health records


12-3

Learning Outcomes (cont.)
12.4 Illustrate the steps in creating a new patient
record and correcting an existing record
using EHR software.
12.5 Describe some of the capabilities of EHR
software programs.
12.6 Explain how you might alleviate a patient’s
security fears surrounding the use of EHR.

12-4

Introduction
• Electronic health records
– Eliminates duplication forms
– Simply review information


12-5

A Brief History of Electronic Medical
Records
• Paper records becoming inadequate
• Medical errors due to
– Lost or misfiled records
– Mishandled patient messages
– Inaccurate and illegible documents
– Mislabeled or illegible lab or medication
orders


12-6

Apply Your Knowledge
What are the four errors that stem from
communication problems?
ANSWER: They are:
Lost or misfiled records
Mishandled patient messages
Inaccurate and illegible documents

Mislabeled or illegible lab or medication
order


12-7

Electronic Records
• Electronic medical record (EMR)
• Electronic health record (EHR)
– Continuity of care
– Reduction in errors
– Decreased costs
• Personal health record (PHR)


12-8

Apply Your Knowledge
• Match the following:
ANSWER:
EHR
PHR
EMR

PHR

PHI that is collected an maintained by
the patient

EHR

conforms to national interoperability
standards

PHR

not a legal record

EMR

used by a single healthcare
organization

All three

covered by HIPAA


12-9

Advantages and Disadvantages of EHR
Government mandate steps
1. Use all major functions of EHR
2. Use EHR to send and receive clinical
information


12-10

Advantages and Disadvantages of EHR

(cont.)

3. Clinical decisions support (in development)
•
•
•
•

High priority conditions
Enrolling patients in PHR
Accessing comprehensive data
Improving population health

• E prescribing
• Incentives


12-11

Disadvantages of EHR Programs
• Disadvantages
– Costly
– Staff training requirement
– IT staff may be needed
– Possible damage to system and software and
or required upgrades


12-12

Advantages of EHR Programs
• Fewer lost medical records
• Eliminated transcription costs
• Increased readability/legibility
• Ease of chart access for multiple users
• Chart availability outside of office hours


12-13

Advantages of EHR Programs (cont.)
• Increased access to patient education materials
• Decreased duplication of test orders
• More efficient transfer of records
• More efficient billing processes
• Greatly decreased storage needs


12-14

Advantages of EHR Programs (cont.)
• Accessed from other locations
– Physician’s home
– Satellite offices

• Used in teleconferences


12-15

Apply Your Knowledge
What is the main reason medical practices are
not implementing EHRs?
ANSWER: Cost


12-16

Working With an Electronic Health Record
• Basic rules unchanged
• Creating a New Patient Record
• Correcting an EHR


12-17

Working With an EHR (cont.)
• Be familiar with the hardware and software
• Keep password secure
• Check entries carefully before saving


12-18

Apply Your Knowledge

Right!

Which statements are true and which are false?
ANSWER:

F All
____

EHR programs will be
the same.

Although programs must
communicate with each other,
they may not be the same.

___
T The basic rules for working with an EHR are the same
as for a paper record

F

____ Once

you make a mistake in an EHR, there is nothing
you
canmake
do toan
correct
it. with the correct information.
You can
addendum


12-19

Other Functions of EHR Programs
• Tickler files
• Specialty specific
– Customized
– Templates


12-20

Other Functions of EHR Programs (cont.)
• Electronic schedulers
– Advantages
– Disadvantage


12-21

Other Functions of EHR Programs (cont.)
• Eligibility verification and referral management
• Billing and coding


12-22

Other Functions of EHR Programs (cont.)
• Report generators
• Electronic prescriptions

12-23

Other Functions of EHR Programs (cont.)
• Ancillary order integration

• Patient access


12-24

Apply Your Knowledge
Match the following:

ANSWER:

1. Tickler file

6 flags allergies

2. Electronic scheduler

3 checks insurance coverage

3. Eligibility verification

1 sends an alert for follow-up care

4. Billing and coding

2 may send a reminder to the patient

5. Report generator

4 allow for electronic claims to
insurance companies

6. Prescription writer
7. Ancillary order integration
8. Patient access

5 office statistics
8 make an appointment or pay a bill
7 submits orders to the lab

Impressive!


12-25

Security and Confidentiality and EHR
• Access code
– Limits access
– Date and time stamp
• Release of information policy
• Backup