Electronic Health Records docx presentation.pptx

Health Electronic Records

1. Electronic Health Records P. Nyambi

2. What is an Electronic Health Record? Before we answer that, what is a patient record?  commonly referred to as the patient's chart or medical record  amalgam of all the data acquired and created during a patient's course through the heath care system

3. Purpose of a Patient Record

4. Purpose of Patient Records

5. Weakness of the Paper Record System

6. Difference between Paper and Electronic Health Records Accessibility Legibility Adaptive Structure Reusability Flexibility

7. Value of an EHR is determined by

8. Influences on EHR Disease Pattern Change Health Care Delivery System Change Specialization of Medicine Advances of Computer and Information Technology

9. Primary and Secondary Uses of an EHR Primary Uses Patient Care Delivery Patient Care Management Patient Care Support Processes Financial and Other Administrative Processes Patient Self-Management Second Uses Education Regulation Research Public Health and Homeland Security Policy Support

10. Core Functionalities Health Information and Data Results management Order entry/management Decision support Electronic communication and connectivity Patient support Administrative processes Reporting and population health management

11. Health Information and Data Key Data Problem list Procedures Diagnoses Medication list Allergies Demographics Diagnostic test results Radiology results Health maintenance Advance directives Dispositions Level of service

12. Health Information and Data Narrative (clinical and patient narrative) Free text Template based Deriving structures from unstructured text NLP Structured and coded Signs and symptoms Diagnoses Procedures Level of service Treatment plan Single discipline interdiscipline

13. Health Information and Data Patient Acuity/Severity of Illness/ Risk Adjustment Nursing workload Severity adjustment Capture of identifiers People and roles Products/devices Places (including directions)

14. Results Management

15. Order Entry/Management Computerized provider order entry Electronic prescribing Laboratory Microbiology Pathology Radiology Ancillary Nursing Supplies Consults

16. Decision Support Access to knowledge sources Domain knowledge Patient education Drug alert Drug dose defaults Drug dose checking Allergy checking Drug interaction checking Drug-lab checking Drug-condition checking Drug-diet checking

17. Decision Support

18. Decision Support Clinician work list Incorporation of patient and/or family preference Diagnostic decision support Use of epidemiologic data Automated real-time surveillance Detect adverse vents and near misses Detect disease outbreaks Detect bioterrorism

19. Electronic Communication and Connectivity Provider to provider Team coordination Patient-provider Email Secure web messaging Medical Devices Trading partners (external) Outside pharmacy Insurer Laboratory Radiology Integrated medical record Within setting Cross-setting Inpatient-outpatient Other cross-setting Cross-organizational

20. Patient Support

21. Administrative Processes Scheduling management Appointments Admissions Surgery/procedure schedule Eligibility determination Insurance eligibility Clinical trial recruitment Drug recall Chronic disease management

22. Reporting and Population Health Management

23. Barriers Standardization of Clinical Information Cost of implementation and maintenance Physicians' readiness to adopt the EHR Privacy issues and patients’ concerns with information sharing. Legal liability