HSS5301 Electronic patient record

Electronic patient record

The Institute of Medicine (IOM) defined eight core functions or an HER

- Health information and data

- Result management

- Order management

- Decision support

- Electronic communication and connectivity

- Patient support

- Administrative processes and reporting

- Reporting and population health

8 core functions of an HER

- Health Ix and data

Defined set of data that includes items such as medical and nursing dx, medication list, allergier, demographics, clinical narratives and lat test results.

- Result management

n Computerized results can be accessed more easily by the provider at the time and place they are needed.

n Reduced time lag aloows for quicker recognitiona dn treatment of medical problems

n Automated display of previous test results makes it possible to reduce redundant and additional testing

n Better interpretation and for easier detection of abnormalities

n Imrove care coordination among multiple providers, between provider and patients.

- order management

n CPOE system can imrove workflow proceses by eliminating lost orders and ambiu=ities, generating related order automatically.

n COPE for medicaitonsl redices te nmnber of errors of medication dose and frequency, drug-allergy and drug-drug interactions.

n COPE + HER improves clinician productivity

- decision support

n CDSSs include prevention, prescribing of drugs, Dx and managements and detection of afverse events and diseases outbreaks

n Computer reminders and prompts improve preventive practices in areas such as vaccinations, breast cancer screening, colorectal screening, and cardiovascular risk reduction

- administrative processes and reporting

n scheduling system, billing and claims management

n Electronic authorization and prior approval eliminate delays

n Identify patients potentially eligible for clinical trials

n Reporting tools support drug recalls.

- reporting and population health

n reporting requirements of government for P safety and Public health

n labor-intersive and time-consuming

n reporting of key quality indicators

n public health surveillance and timely reporting of adver4se reactions and disease outbreaks

- electronic communication and connectivity

n communication among care partners can enhance patient safety and quality of care, especially for patients who have multiple providers in multiple settings and must coordinate care plans.

n Creating and population HER systems with data from lab, pharmacy, and radiology etc

n Email and web messaging facilitating communication – greater continuity of care and more timely interventions

n Fundamental to the creation of an integrated health records

- patient support

n control of chronic illness, home monitoring, data from home monitoring system merged with HER

CPRI(Computer-based Patient record Institute)

- identified three key criteria for an HER

n capture data at the point of care

n integrate data from multiple sources

n provide decision support

Paper chart vs EHR

- disadvantage of paper records

n often abbrevaitaed

n cryptic

n illegible

n must be transported from one office to another

n not easily searchable

HER – the portions of a P’s medical recods that are stored in a computer system as well as the functional benefits derived from have an electronic health record

- adv: simultaneously access at multiple stes

- esearchable by computer

- data is likely to be standard medical terms

- can be transferred electronically to another system

- Health maintenance

- Trend analysis

- Alerts

- Decision support

Forces driving the HER

- health and safety

- increasingly mobile society

- increased specialization

- internet

- readiness for change

Lab orders and resuls: status

- from beginning of the order to the review of results by the clinicians, there is the issue of order status.

- If too much time elapses between when the patient needs the test and an action is taken based on the tets results, the P’s condition could deteriorate

- To determine how much time has elapsed, the medical office must know which patients have tests pending results and when they were ordered

- The office is then a position to follow-up woth the lab or the patient.

Electronic data interchange

- standards for data transfer enable the direct import of infomraiton into ht eEHR

- HL7

n Messaging standard between healthcare ystsmes

- DICOM

n Most widely used format for sending diagnostic images

- CDISC

n Exchange standard for data used in clinical trials

- Medical devices

n Data exchange often proprietary to the particular device

HL7

- leading messaging standard used to exchange clinical and administrative data between different healthcare computer systems.

- The name of both the non-profit organization and of the standard that it developed and maintains

- Used for the communication of:

n Lab order and result;s

n Radiology reports

n Clinical observations

n Patient demographics

n Many other types of clinical data