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4-2 Learning Outcomes After studying this chapter, you should be able to: 1.Explain the functions of an EHR in an acute care hospital. 2.List the primary benefits of a hospital EHR. 3.List the uses of clinical documentation in an inpatient setting. 4.Discuss the advantages of computerized physician order entry (CPOE). 5.Explain how decision-support tools improve the quality of patient care.

4-3 Learning Outcomes After studying this chapter, you should be able to: 5.Describe how CPOE and electronic medication administration records (eMAR) work together to reduce medication errors. 6.Describe the advantages of electronic results reporting over traditional paper-based reporting systems.

4-4 Key Terms adverse drug event (ADE) computerized physician order entry (CPOE) electronic medication administration record (e-MAR) five rights medication administration record (MAR) medication reconciliation order sets transition points

4-5 The Need for Clinical Information Systems Factors responsible for increased use of EHRs and clinical information systems in hospitals: –medical errors –amount of available medical information –quality standards

4-6 Complexity of Hospital Information Systems Physician offices typically maintain one clinical information system. Hospitals have numerous clinical information systems including laboratory systems, pharmacy systems, radiology systems, and various others.

4-7 Components of an Inpatient EHR Clinical documentation Computerized physician order entry Clinical decision support Electronic prescribing and electronic medication administration records Electronic results reporting

4-8 Medication Management Medication errors are most frequent source of preventable medical errors in hospital setting. medication administration record (MAR) = log containing information about the order and documentation of administration of medication to patient

4-9 Medication Management adverse drug event (ADE) = side effect or complication from medication transition points = times when patients move from one location to another medication reconciliation = comparing patient’s list of medications at admission with medications ordered during hospital stay; if different, must be reconciled before any drug is administered

4-10 Electronic Medication Administration Record (eMAR) electronically track medication administration via bar coding to verify compliance with the five rights of medication administration: –the right patient –the right medication –the right dose –the right time –the right route

4-11 Results Reporting allows providers to receive and review laboratory and imaging test results from within the EHR. Whenever laboratory, radiology, or other tests are performed in the hospital, the ordering clinician is notified when results are available; the test results are automatically sent to the patient’s EHR

4-12 Digital Images Digital images of radiology results are created and stored in picture archiving and communication systems (PACS) PACS transfers the data to EHRs giving physicians access to results

4-13 Advantages of Electronic Results Reporting faster turnaround time faster diagnosis and treatment efficient consultations faster medication administration fewer duplicate tests enhanced analysis easier retrieval