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

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
A medical record is otherwise known as a medical chart, patient chart, or medical (patient) file.
Have students discuss the different ways the medical record has been used throughout history.

3. 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
Documentation is the process of recording data about a patient’s care and health status. Documentation is done in a chronological order.
Some of the contents of the medical record overlap. For example, the HIPAA form is both an administrative and legal form.

4. Health Information Medication lists Allergy lists Immunization records
Laboratory reports
Pathology reports
Surgical reports
Hospital records
H&P
Progress notes
Radiology reports
Ask students to provide examples of the different types of forms presented. An example of a radiology report would be ankle x-ray, MRI of the brain, or CT of the abdomen.

5. Administrative Information
Patient information form
Referral letters
Consultation letters
Insurance information
Billing information
Appointment history
Diagnostic and procedure codes
Emergency contact information
Patient information form: a form used to gather data about the patient, including contact information, health history, demographics, etc.
Ask students the difference between a “referral” and “consultation” letter. Answer: A referral is a transfer of care, whereas the consultation is when the primary provider asks for an opinion from a specialist.

6. Legal Documents Records release Informed consent documents HIPAA forms
Advance directives
Living wills
Insurance authorization forms
Healthcare power of attorney forms
Informed consent documents are documentation that a patient has agreed in writing to have a specific treatment or procedure done.
A living will states a person's wishes regarding certain medical treatment. A living will goes into effect while you're still alive but unable to communicate.

7. 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
The medical assistant will generally document the chief complaint (reason for patient visit), history of present illness, and vital signs in the chart during a patient appointment.
Different providers would include: physician assistants, nurse practitioner, physical and occupational therapy, social worker, specialist, surgeons, patient educators.

8. 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
The charge for records is based on the cost of preparation and production of the medical record.
Doctrine of Professional Discretion states the doctor may exercise their best judgment when deciding whether or not to share progress notes with a patient being treated for mental or emotional disturbances.

9. The Electronic Health Record (EHR)
Patient medical record in an electronic format
Eight core functions of an EHR system

10. Eight Core Functions Health information & data management
Results management
Order management
Decision support
Electronic communication & connectivity
Patient support
Administrative processes
Reporting and population health
These eight core functions were created by the Institute of Medicine (IOM) in 2003 as a set of standards that EHRs should accomplish.

11. Transitioning from Paper to Electronic Records
Office of the National Coordinator of Health Information Technology (ONCHIT)
Computerized physician order entry (CPOE)
Slow and steady process. In only 17% of practices have adopted EHRs.
UNN Easing the Transition 1-1. Discuss with students the reasons for medication errors and ways the EHR can eliminate these problems.

12. 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
The line between these terms has blurred to the point that they are now used virtually interchangeably, although there has been a shift toward EHR as the preferred term.

13. Practice Partner Basic Functions
Progress note
Documentation templates
Provider review of incoming data
Image attachment
Electronic signature insertion
Prescription (CPOE) templates
Fax & messaging
Patient reminders
Vital signs data
Importation of data
Automatic flagging
Print
These are the basic functions covered in the text book.

14. Clinical Decision Support (CDS)
Automated preventive care reminders
Treatment plan templates
Generates pt. data reports
Documentation templates
Automatic reminders are only helpful if they are used by the physician. Some providers find them helpful, others prefer to rely on their own treatment methods.

15. Practice Management Software
Administrative software used for:
Patient demographics
Billing and insurance information
Appointment scheduling
Advanced accounting practices
Many of these tasks are part of the electronic health record, and many types of practice management software interface with EHRs. Example: Medisoft is a practice management software that works together with Practice Partner.

16. Practice Management
Figure 1-2 Sample insurance cards. Point out the “Copayment” area.
Figure 1-3 Sample daysheet that itemizes the financial activity of each day.

17. Practice Management (cont’d.)
Figure 1-4 CMS 1500 form. Used to submit claims for reimbursement.
The information needed to complete this form will come from the patient record and encounter form.

18. 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
Ask students to provide examples of these advantages.

19. EHR Disadvantages Lack of interoperability Cost Financial investment
Time
Employee resistance
Regimentation
Security gaps
Ask students to describe how these are disadvantages.

20. Early and Late Adopters
The following factors affect user satisfaction:
Length of system response time
Perception of workflow logic
Ability to complete tasks
Ease of mistake correction
Training time
Availability of support staff
System effect on quality of care
Ability to convert systems to specific provider needs
Level of computer skills
Ask students to think about their own adoption of technology. Are they the first person to run out and get the newest Internet phone, or are they slower to get the new technology? What are their reasons for choosing to adopt or not adopt?

21. Role of the Healthcare Professional
Basic skills needed:
Knowledge of medical terminology
Basic typing and computer skills
Organizational skills
Interpersonal skills
Ask students to brainstorm other skills or traits that are needed to work in a medical office. Sympathy, empathy, willingness to help others, willingness to learn new skills, reliability, etc.

22. Administrative Duties
Receptionist duties
Appointment scheduling
Electronic chart creation
Purging
Entering patient data
Creating patient letters
communication
Patient education
Coordination of care
Ask students how they think these duties will change with the implementation of the EHR.

23. Clinical Duties Document treatment Coordinate patient care Document:
Patient H&P
Vital signs
Progress notes (details of patient visit)
Laboratory requisitions
Prescriptions
Test results
Ask students how they think these duties will change with the implementation of the EHR.

24. Billing and Coding Duties
Creation of billing statements
Assignment of procedural and diagnostic codes
Link codes for reimbursement
Auditing
Filing patient statements
Ask students how they think these duties will change with the implementation of the EHR.

25. Professional Organizations
Benefits:
Offer certification exams
Continuing education unit (CEU) opportunities
Networking
Newsletters and professional journals
Discounts on publications
Sponsor conferences, workshops, and web-based activities
Learning should be lifelong, especially when you are working in the medical field. These professional organizations have benefits for belonging and make it rather easy to keep up with the newest medical trends.

26. Professional Organizations (cont’d.)
American Health Information Management Association (AHIMA)
American Academy of Professional Coders (AAPC)
American Association of Medical Assistants (AAMA)
American Medical Technologists (AMT)
Depending on what field of healthcare you are planning to enter, you could belong to one or more of these organizations. Each has a membership fee that must be updated periodically. Many have student discounts available.