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Electronic Health Records

Electronic Health Records. Presented by Jerome Scott. Objectives. Describe the common components of Electronic Health Records (EHR). Assess the benefits of an EHR. Evaluate outcomes of EHR use in meeting needs of healthcare staff and patients. Electronic Health Record (EHR).

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Electronic Health Records

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  1. ElectronicHealthRecords Presented by Jerome Scott

  2. Objectives • Describe the common components of Electronic Health Records (EHR). • Assess the benefits of an EHR. • Evaluate outcomes of EHR use in meeting needs of healthcare staff and patients.

  3. Electronic Health Record (EHR) The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. (Electronic Health Record, 2010) Click for Reference

  4. The benefits of EHR • Avoid duplication of tests • Reduce medical errors • Make surgery safer • Encourage better self-care • Improve care of chronic illness • Identify proper medication dosages

  5. EHR Components • Hardware • Software

  6. Hardware The physical or tangible parts of the EHR computer system • Computer terminals in patient care areas • Tablet PC’s • Handheld devices

  7. Hardware example Tablet PC • High mobility PC • Lightweight and high durability • Slim, flat battery is hot-swappable • Thin dimensions can be easily gripped • Three input modes (pen, voice & keyboard)

  8. EHR software offers integrated clinical and administrative capabilities and provides quick access to patient information • Computer Physician Order Entry • Security software • Lab Test Results • Patient-specific Educational Resources • Electronic Syndrome Surveillance • Immunization registries

  9. Security software Software protection of sensitive patient Information

  10. Security access control • Individual-based access • Role-based access • Context-based access

  11. Individual-based access control Each user’s information needs is individually evaluated and access is provided accordingly.

  12. Role-based access control Users with common jobs and/or access needs • Nurses • Administrators • Secretaries

  13. Context-based access control Users who serve in a common context • Specific discipline • Legal entity

  14. Software Healthcare information systems: • Clinical • Pharmacy • Laboratory • Radiology

  15. Software must address the three axioms of usability • Early and central focus on users in the design, development and purchase of systems • Iterative design • Empirical usability measures of observations of users and information systems (Staggers, 2003) Click for Reference

  16. PATIENT CARE TEAM Laboratory Physicians office Emergency Services EHR= Continuity of care Pharmacy Hospital Specialist Home Health Radiology

  17. Clinical Information systems Enhancing care by providing data at the bedside • Containing observations • Interventions • Clinical notes • Hemodynamic data • Lab results

  18. Chronic care management software Electronic chronic care management is aimed at improving the health of patients with chronic illness

  19. Chronic care management software areas • Heart disease • Hypertension • Chronic Obstructive Pulmonary Disease (COPD) • Asthma • Diabetes

  20. EHR package examples MedicsDocAssistant Electronic Health Records software • Physicians Quality Reporting Initiative (PQRI) • Computer Based Provider Order Entry (CPOE) • Evidence-Based Medicine • MedicsRX e-prescribing Solution • Medics On-Call™ for iPhone™ • Virtual "sticky notes“ (MedicsDocAssistant Electronic Health Records, 2010) Click for Reference

  21. Nurse informatics competencies • Systems analysis, design, and implementation • Database management • Specialization in health care informatics • Current issues and trends in health care informatics • Health care informatics internship

  22. Nurse informatics responsibilities • Clinician computer education coordination • Project management for clinical systems • Supervises clinical informatics analysts • Leads nursing informatics vision and strategic plan

  23. Disadvantages of EHR • Start up costs • Transition period from paper to electronic • Feelings of depersonalization • Distraction from the patient • Computer problem delays • Security

  24. Ethical and legal issues with HER • Third party access • Confidentiality • Beneficence and nonmaleficence • Value conflicts

  25. References Electronic Health Record. (2010). Retrieved February 25, 2010, from Healthcare Information and Management Systems Society (HIMSS) Web site: http://www.himss.org Staggers, N. (2003). Human factors: Imperative concepts for critical care. AACN Clinical Issues , 310-319. MedicsDocAssistant Electronic Health Records. (2010). Retrieved March 2, 2010, from Advanced Data Systems Corporation: http://www.adsc.com Return

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