Module 3 Roles and Their Transformations on the Way to Electronic Medical Records

Module 3 Roles and Their Transformations on the Way to Electronic Medical Records

OBJECTIVES


Describe electronic health records(EHR), electronic medical records (EMR) and personal health records (PHR).
Explain the difference between electronic health records (EHR), electronic medical records (EMR) and personal health records (PHR).
Discuss the difference between clinical information systems (CIS) and administrative information systems (AIS).
Identify electronic record systems utilized within the hospital and clinic settings.
Discuss personal rating of these hospital and clinic record systems.
Identify strengths and weaknesses of these hospital and clinic record systems.

WHAT ARE ELECTRONIC HEALTH RECORDS (EHR)

Electronic health records are digital computerized versions of the patient’s paper charts.

Health records are collections of patient health data.

Health records are data reported by multiple health
care providers.

Health records include vital signs, age, weight, medications, allergies, medical examination results, radiology images.

(Roehrs, 2017)
Speaker Notes:
EHR definition-a digital repository of the health status of patients.
EHR evolved from multiple electronic methods of storing patients’ health data.
V/S=body temperature, pulse, respiration, and blood pressure

3

WHAT ARE ELECTRONIC MEDICAL RECORDS (EMR)
Electronic medical records are stored within the clinic or facility that created them.
Electronic medical records are data imputed by the clinical care providers within that clinic or facility.
Electronic medical records are not shared outside the provider’s practice digitally.

(Hebda, 2021)
Speaker Notes:
EMR=saves clinicians time through more efficient processes and timely access to clinical care provided by other clinicians.
EMR=saves money through improved medical productivity,.
EMR=ensures legible documentation and shorter wait times as providers can access data in minutes.

4

WHAT ARE PERSONAL HEALTH RECORDS
A personal health record is a collection of a person’s health records.
A patient is the only one who can access, manage and share their personal health records. 
Personal health records can be in digital or paper format.
A patient can choose to share their health data with health care providers or keep them private.
Personal health records can provide vital information in emergency care.
(Ose,2017)
Speaker Notes:
Ex: doctor’s names, medications, allergies, surgeries, family history, personal health goals, advanced directives.
Pt’s rarely have the paper format, may use USB devices.
Digital PHR are more convenient for providers to reference during visits.
5

COMPARISON OF RECORDS
EMR-Patient data is managed in one facility.
*Not accessible to other providers.

EHR- Sharing and importing options are available by other facilities.
*No patient access.

PHR- data is controlled by the patient .
*Access of data by facilities is at the discretion of the patient.
(Ose,2017)
Speaker Notes:
Group Question- Does anyone have a personal health record they access?
If so, How often do you access your PHR for information?

6

CLINICAL INFORMATION SYSTEMS (CIS)
clinical information systems organizes and stores patient medical information electronically.

clinical information systems usually are limited to a single service like laboratory, cardiac monitoring, vital signs, x-rays.

clinical information can be incorporated into patients’ electronic medical records.

(Fraekel, 2021)
Speaker notes: Clinical Information System (CIS) is a computer-based system that is designed for collecting, storing, manipulating and making available clinical information important to the healthcare delivery process.
Examples:
Electronic medical record (EMR)
Nursing documentation
Medication administration
Computerized provider order entry (CPOE)
Telemedicine

7

ADMINISTRATIVE INFORMATION SYSTEMS (AIS)
Administration information comprised of patient and employee document storage, retrieval, and archiving capabilities.
Administrative information communicates with multiple hospital departments.
Administrative information systems are designed to meet the needs of organizational needs.

(Hebda, 2021)
Speaker notes:
AIS supports patient care by managing financial and demographic information and reporting capabilities.
Examples:
Scheduling- registration
Pt billing
Coding
Utilization review-risk management
Payroll
Human resources
8

(Fusion, 2021)
DIFFERENCE BETWEEN CIS AND AIS
Clinical information Systems

Directly support patient care

Able to be stand alone systems

Exchanges electronic data with all systems
Administrative information systems

Indirectly support patient care

Able to operate in its own system

Exchanges data to internal systems
Specker notes:
Clinical information system is used for patient care
Administrative information system is used both for employee and patient billing
9

HOSPITAL INFORMATION SYSTEMS IN USE
CPSI
TruBridge
Evident-Thrive
E-prescriptions
Praxis
Speaker notes:
Systems utilized in the hospital settings for med surg, human resources, billing and scheduling dept’s, ob units, doctors & specialist, ect.
10

Module 3 Roles and Their Transformations on the Way to Electronic Medical Records

CPSI SYSTEM
The Computer Programs & Systems (CPSI) is utilized in these hospital departments
Acute care
Ambulatory care
Post-acute care
Patient billing
Medical coding
IT services

Speaker notes: Electronically accessed by clinical, business and provider staff members.
11

TRUBRIDGE
TruBridge business system provides internal operations of these services

Interim staffing
Accounts receivable management services
Early out services
Insurance follow up services
Medial coding service
Contract management

Speaker notes:
The hospital business and human resource department utilize this system to track medical coding, employee payroll, insurance and biling.
12

Module 3 Roles and Their Transformations on the Way to Electronic Medical Records

EVIDENT-THRIVE
Evident thrive is a system used by hospital providers, surgeons and specialists

Interfaces with the EHR
Oral dictation capability
Accessibility by cloud technology
Provider charting predictability
Speaker notes:
This system is used by all the hospital doctors providing treatments in house. This system provides accurate recorded dictation in all aspects of patient care.
13

E-PRESCRIPTIONS
Electronic prescribing is a system used by doctors, surgeons, practitioners to send medication orders to outside pharmaceutical companies

Safer controlled medication prescribing

Faster medication access for patients

Patients aware of insurance costs quicker

Patient medication reference for providers

(Jakubowski, 2018)
Speaker notes:
E-prescribing is when a provider sends a prescription electronically to a pharmacy.
E-prescribing allows providers, with patient consent, to access the patient’s medication history and to know the patient’s prescription benefits prior to sending the prescription.
14

Module 3 Roles and Their Transformations on the Way to Electronic Medical Records

PRAXIS
Praxis is an OB-GYN electronic health care system

Collaborate with other providers for patient care needs
Manages parient health and maintenance
Leading-edge disease management
Runs online queries and studies

Speaker notes:
Praxis is used in the hospital department and OB-GYN clinic to manage patients as they progress through pregnancy and to meet gynecological needs.
15

HOSPITAL SCORE IN ELECTRONIC SYSTEMS
The hospital rates 8 out 10 for electronic capabilities, functioning, and versatility.

Patient portal options are available

Provider access and dependability

Employee training, insurance and payment systems

Varied hospital departmental personalized systems

Speaker notes:
Multi-functioning electronic health record systems, personalized departmental system technology, cloud-based communication and accessibility
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STRENGTHS AND WEAKNESSES OF CPSI
Documentation cannot be removed from the electronic medical record.
Electronic systems are more efficient and an effective tools for time sensitive care.
More patient health information is available at the time of care.
Hospitals still have privacy breach risks with printouts such as patient discharge instructions or after visit summaries.

Staff need to ensure that patients receive the correct printouts not ones for a different patient

Module 3 Roles and Their Transformations on the Way to Electronic Medical Records

Electronic medical records, it is much easier to be working in the wrong patient record
(Strauss, 2016)
Speaker notes:
Electronic health access is a modern tool for the convenience of patients and providers.
Many forms of patient records are still paper format, billing statements, insurance EOBs, discharge summaries, ect.
Breaches can happen when patients leave personal records laying around.
17

REFERENCES

Fraenkel, D. (2021). Clinical information system – an overview. ScienceDirect Topics. https://www.sciencedirect.com/topics/medicine-and-dentistry/clinical-information-system

Hebda, T., Hunter, K, Czar, P. (2021). Handbook of Informatics for Nurses & Healthcare Professionals 6th edition

Jakubowski, S., Romaszewski, A., Wypyszewska, J., Gajda, K., & Kielar, M. (2018). E-prescription. Selected legal and functional aspects. Zeszyty Naukowe Ochrony Zdrowia.Zdrowie Publiczne i Zarzadzanie Article 16(3), 137-148. http://dx.doi.org/10.4467/208426270Z.10.016.10429

Ose, D., Kunz, A., Pohlmann, S., Hofman, H., Qreini, M., Krisam, J., Uhlmann, L., Jacke, C., Winkler, E. C., Salize, H., & Szecsenyi, J. (2017). A personal electronic health record: study protocol of a feasibility study on implementation in a real-world health care setting. JMIR Research Protocols, Article 6(3)http://dx.doi.org/10.2196/resprot.6314

Roehrs, A., da Costa, C. A., Rodrigo da, R. R., & Kleinner Silva Farias, d. O. (2017). Personal health records: A systematic literature review. Journal of Medical Internet Research, Article 19(1)http://dx.doi.org/10.2196/jmir.5876

Strauss, L. J. (2016). Electronic medical records – benefits and liabilities. Journal of Health Care Compliance, Article 17(2), 57-58. https://www.proquest.com/trade-journals/electronic-medical-records-benefits-liabilities/docview/1664142250/se-2?accountid=34574

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