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Chapter 2
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  1. Electronic Health Records for Allied Health Careers Cover goes here when ready Chapter 2 Transitioning to an Electronic Health Record and the Need for Clinical Information Standards

  2. Learning Outcomes • After studying this chapter, you should be able to: • Describe the major strategies for converting paper-based charts to EHR. • List the four ways of entering live patient data into EHR. • Explain how desktop, laptop, and tablet computers differ. • Discuss the advantages of wireless networks in health care. • Explain the major difference between locally hosted and ASP hosting models.

  3. Learning Outcomes • After studying this chapter, you should be able to: • Discuss why the adoption of clinical standards is critical to the successful implementation of electronic health records. • Describe the difference between clinical vocabularies and classification systems. • List four messaging standards used with electronic health records. • Describe the significance of the Medicare Prescription Drug and Modernization Act of 2003 in the adoption of clinical standards.

  4. application service provider (ASP) classification systems clients clinical templates clinical vocabularies Current Procedural Terminology (CPT) content standards desktop computer Digital Imaging and Communications in Medicine (DICOM) Healthcare Common Procedures Coding System (HCPCS), Level II Health Level Seven (HL&) hybrid conversions incremental conversion Institute of Electrical and Electronics Engineers 1073 (IEEE1073) International Classification of Diseases, Ninth Revision interoperable laptop computer locally hosted Logical Observation Identifiers Names and Codes (LOINC) messaging standards Key Terms

  5. National Council for Prescription Drug Program (NCPDP) network outsourcing personal digital assistant (PDA) picture archiving and communication system (PACS) scanning server smart phones Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) tablet computer total conversion Unified Medical Language System (UMLS) voice recognition wired network wireless networks workstations Key Terms

  6. Converting Existing Records • Conversion strategies: • Total conversion • Incremental conversion • Hybrid conversion

  7. Entering Live Data • Methods: • dictation and transcription • clinical templates • voice recognition • scanning

  8. Computer Requirements • Input Devices • Workstations • desktop computers • laptop computers • tablet computers • personal digital assistants (PDAs) • smart phones

  9. Computer Requirements • Networks • server = “hub” of network; houses data and applications • clients = computers that access the server over the network • wired network vs. wireless network

  10. Hosting Choices • Locally Hosted Model • Application Service Provider Model • Blended or Hybrid Model

  11. The Importance of Clinical Standards • For shared information to be useful, computer systems must be interoperable • No mandatory standards for clinical data exist yet.

  12. Clinical Information Standards • Clinical vocabularies • Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) • Logical Observation Identifiers Names and Codes (LOINC) • U.S. National Library of Medicine Unified Medical Language System (UMLS)

  13. Clinical Information Standards • Classification systems • International Classification of Diseases, Ninth Revision (ICD-9) • International Classification of Diseases, Tenth Revision (ICD-10) • Current Procedural Terminology (CPT) • Healthcare Common Procedures Coding System (HCPCS), Level II

  14. Clinical Information Standards • Messaging Standards • Health Level Seven (HL7) • Digital Imaging and Communications in Medicine (DICOM) • Picture Archiving and Communication System (PACS) • National Council for Prescription Drug Program (NCPDP) • The Institute of Electrical and Electronics Engineers 1073 (IEEE1073)

  15. Clinical Information Standards • EHR Content Standards • Electronic Health Record System Functional Model (EHR-S-FM)