Chapter 6 Electronic health records pptx

Data record

1. 2/3/2022 1 Electronic Health Record( EhR )

2. Learning Outcomes After completing this topic you should be able to: Define EHR Identify the benefits of EHRs List the key components of an EHRs 2 2/3/2022

3. Personal Health Record 2/3/2022 3 A tool you can use to gather, organize and manage your health care information, including medical history, medications, immunizations etc. You control the PHR: Enter your medical info Decide who gets access Update info E.g. Google Health

4. Electronic Medical Record 2/3/2022 4 The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization (CDO) who are involved in the individual’s health and care. Your health care provider controls the EMR.

5. EMRs allow clinicians to: 2/3/2022 5 Track data over time Easily identify which patients are due for preventive screenings or checkups Check how their patients are doing on certain parameters such as blood pressure readings or vaccinations Monitor and improve overall quality of care within the practice

6. Electronic Health Records System 2/3/2022 6 The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.

7. Electronic Health Record (EHR) The term EHR is widely used in many countries with variation in definitions and the extent of coverage. EHR is generally accepted as a longitudinal health record with entries by healthcare practitioners in multiple sites where care is provided. EHR contains all personal health information belonging to an individual & it is entered & accessed electronically by healthcare providers over the person’s lifetime. 7 2/3/2022

8. Paper based Medical Record System Advantages Disadvantages Low starting cost Difficult to retrieve, store & share Simple staff training Illegibility Less technically trained staff Difficult to abstract information No Downtime Easy to destroy/damage Electronic Health Record System Improve access Increased start-up costs Enhanced Patient information security Selection and development of system is time consuming Easy to update Staff training is time-consuming Timely capture of data User resistance can occur 8 2/3/2022

9. Components of EHR system There are many types of EHRS used in healthcare facilities. However, in all EHR systems, there are two major components of the system: The administrative modules: support patient registration, scheduling/appointment, admission/discharge, financial and other management processes. The clinical modules: enable the users to collect, store and display clinical information related to preventive and curative healthcare services. 9 2/3/2022

10. Benefits of EMR for Health care Practice Quality of Care and Patient Safety Benefits . EMRs improve the quality of patient care by: Improving the quality of & access to patient information. Reducing clinical errors. Helping doctors keep more complete records. Giving decision support to practitioners. Helping to improve clinical practices. 10 2/3/2022

11. Cost-of-Care Benefits . EMRs can reduce costs by: Reducing redundant tests due to unavailability of test results. Generating & submitting reports automatically. Enhancing productivity through reducing: The time spent searching for records. Redundant data entry. Reducing risks to the patient, and thus unnecessary costs of care arising out of: Decisions that are delayed due to inability to access information. Repeating invasive tests and procedures. 11 2/3/2022

12. Communication Benefits . EMRs improve communication by: Improving access to clinical information. Improving the sharing of health information among primary care professionals. Improving the flow of information with secondary and tertiary care teams. Providing patients with better access to their own records. 12 2/3/2022

13. Analysis benefits. EMRs improve analysis of health related data by: Providing easier observation of trends and patterns in the health of a patient, making clinical audit, outcome assessment, and research easier. Enhancing the ability to analyze data to support management decision making. Enabling the demonstration of clinical competence for revalidation and certification purposes. 13 2/3/2022

14. In reality, any software that assists decisions is a CDSS. CDSS is an interactive decision support system, which is designed to assist physicians and other health professionals with decision making tasks, as determining diagnosis of patient data. CDSS is an application that analyzes data to help healthcare providers make clinical decisions. Clinical Decision Support Systems (CDSS) 14 2/3/2022

15. Purpose/Goal To assist clinicians at the point of care. This means that a clinician would interact with a CDSS to help determine diagnosis, analysis, etc of patient data. Previous theories of CDSS were to use the CDSS to literally make decisions for the clinician. The clinician would input the information and wait for the CDSS to output the “right” choice and the clinician would simply act on that output. 2/3/2022 15

16. Purpose … 16 The new methodology of using CDSS to assist forces the clinician to interact with the CDSS utilizing both the clinician’s knowledge and the CDSS to make a better analysis of the patients data than either human or CDSS could make on their own. Typically the CDSS would make suggestions of outputs or a set of outputs for the clinician to look through and the clinician officially picks useful information and removes erroneous CDSS suggestions. 2/3/2022