1. Chapter 1 Introduction to Electronic Health Records Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

2. 2 What is a Medical Record?  A physical collection of an individual’s healthcare information  Used throughout history to document:  Patient healthcare  Signs and symptoms  Diseases  Trends of disease

3. 3 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Paper medical record

4. 4 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Paper, paper, and more paper !  HELP !

5. 5 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Contents of the Electronic Health Record  Each patient has their own record  Documentation is a vital component of the EHR  Contains:  Health information  Administrative information  Legal documents

6. 6 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Health Information  Medication lists  Allergy lists  Immunization records  Laboratory reports  Pathology reports  Surgical reports  Hospital records  H&P  Progress notes  Radiology reports

7. 7 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. EHR is the paper health record in electronic format.  Electronic Health Record

8. 8 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Pair and Share- Review  Discuss with your partner the following questions.  1- What is EHR ?  2- List 3 items found in EHR.  3- Name 4 items found in the Electronic Health Record.

9. 9 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Administrative Information  Patient information form  Referral letters  Consultation letters  Insurance information  Billing information  Appointment history  Diagnostic and procedure codes  Emergency contact information

10. 10 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Legal Documents  Records release  Informed consent documents  HIPAA forms  Advance directives  Living wills  Insurance authorization forms  Healthcare power of attorney forms

11. 11 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Informed consent  Patient agrees in writing to have specific medical procedure or treatment done.

12. 12 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Pair and Share- Review  Discuss with your partner the following questions.  1- Name 3 examples of administrative information.  2- Name 3 examples of legal documents.  3- What is informed consent ? Why is it important ?

13. 13 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Documenters of the Medical Record  Individual who is responsible for inputting information into the medical record: documenter  Receptionist  Medical assistant  Physician (or other treating professional)  Medical biller

14. 14 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Ownership of the Medical Record  Property of the individual who created it  Physician office owns the physical record  Patient owns the medical information  May obtain a copy by signing a records release  May be charged an administrative fee

15. 15 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Eight Core Functions  Health information & data management  Results management  Order management  Decision support  Electronic communication & connectivity  Patient support  Administrative processes  Reporting and population health

16. 16 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Pair and Share - Review  Discuss with your partner the following questions.  1- Name 3 documenters of medical records.  2- Who owns the medical record ?  3- Name 3 of the 8 core functions of EHR.

17. 17 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. EHR Versus EMR  Interconnected aggregate of all the patient’s health records  From multiple providers  From multiple healthcare facilities  Electronic patient record created & maintained  Component of the EHR

18. 18 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Practice Management Software  Administrative software used for:  Patient demographics  Billing and insurance information  Appointment scheduling  Advanced accounting practices

19. 19 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Practice Management

20. 20 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Practice Management (cont’d.)

21. 21 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. EHR Advantages  Improved quality and continuity of care  Management of chronic disease  Disaster preparedness  Job & patient satisfaction  Increased efficiency  Improved documentation  Easier accessibility at point of care  Better security  Reduced expense

22. 22 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. EHR Disadvantages  Lack of interoperability  Cost  Financial investment  Time  Employee resistance  Regimentation- (rigid organization for regulation or control)  Security gaps

23. 23 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Pair and share- Review  Discuss with your partner the following questions:  1- Name 3 EHR advantages.  2- Name 3 EHR disadvantages.

24. 24 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Role of the Healthcare Professional  Basic skills needed:  Knowledge of medical terminology  Basic typing and computer skills  Organizational skills  Interpersonal skills

25. 25 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Administrative Duties  Receptionist duties  Appointment scheduling  Electronic chart creation  Purging  Entering patient data  Creating patient letters  Email communication  Patient education  Coordination of care

26. 26 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Pair and share question- How will these duties change with EHR ?  Medical Receptionist

27. 27 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Clinical Duties  Document treatment  Coordinate patient care  Document:  Patient H&P  Vital signs  Progress notes (details of patient visit)  Laboratory requisitions  Prescriptions  Test results

28. 28 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Pair and share question- How will these duties change with EHR ?  Medical Providers (Clinical)

29. 29 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Billing and Coding Duties  Creation of billing statements  Assignment of procedural and diagnostic codes  Link codes for reimbursement  Auditing  Filing patient statements

30. 30 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Pair and share question- How will these duties change with EHR ?  Billing and coding

31. 31 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Professional Organizations  American Health Information Management Association (AHIMA)  American Academy of Professional Coders (AAPC)  American Association of Medical Assistants (AAMA)  American Medical Technologists (AMT)

32. 32 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Activity: Visit one of the professional organization websites.  1- Which site did you visit ?  2- What profession does it support ?  3- Are there certifications available through that organization ?