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
