Electronic Medical Record Systems

1. Electronic Medical Record Systems Session 3 – Who has access to what? And how do you enter vital signs into an EMR system?

2. Session 3 Sessions 1 & 2 defined EMR and showed how EMR records differ from paper records. In OpenEMR you logged in, added a new patient, and located information about a patient. Now let’s look at how HIPAA affects EMR access. Then you’ll practice recording vital signs in an EMR.

3. Go to the open-EMR website. Click on this link: http://demo.open-emr.org:2100/openemr/interface/login/login_frame.php (If you’re looking at slides, right-click on the link and choose “open hyperlink,” or else copy the link.) Let’s see how HIPAA affects the way an EMR works

4. This is the screen that should appear

5. Log in to the EMR. Enter this information Username: receptionist Password: receptionist

6. Is this what you see? If so, then you’ve logged in correctly.

7. Which of the following can you access as Receptionist?a. Office Scheduleb. New Encountersc. Patient Reportsd. Procedurese. Demographicsf. Medical Problemsg. Vital Signs • Click on the list of items at the left of the screen. If you are allowed to see an item, it will open. If you aren’t allowed, the item will be grayed out, and you will get this message if you click on the item.

8. Answer Why are you limited to seeing only a few pieces of information about patients? As Receptionist you can access only Office Schedule and Demographics

9. Access is determined by role • One way an EMR system differs from paper is in access. With paper, anyone who touches the file has access to the records. • In an EMR, you have to have certain “access rights” in order to see different information. These rights are determined by your work role. • For instance, the physician may have access to everything in a patient’s record. • A receptionist, on the other hand, may be able to see only certain parts of that record – the parts that are necessary to perform his or her work.

10. How HIPAA affects EMRs The Health Insurance Portability and Accountability Act (HIPAA) of 1996 has a privacy provision that limits who can see a patient’s records. • If you need to see patient information to do your job, then you can have access to it. • If you don’t need that information to perform your work, then you should not have access. That’s to protect the patient’s privacy. For more information, you can check out the HIPAA Website

11. Now let’s add vital signs for a patient • Log out as receptionist. • Log in again, this time as Clinician. Username: clinician Password: clinician

12. This screen appears.

13. How much can you see as “clinician”? Which of the following can you access in your role of Clinician? a. Office Schedule b. Demographics c. Vitals d. Patient Results of Procedures e. Clinical Reminders f. Medical Problems g. Billing and Payment

14. How well did you do? • If you guessed a, b, c, d, e and f, you are correct. • As Clinician, the only set of data you cannot access is category g. Billing and Payment.

15. Now, add the patient for whom you will enter vital signs. • Add this patient: • Name: Henry P. Patient • External ID: Driver’s license • Date of Birth: January 3, 1964 • Sex: M • Social Security No: 555-55-5551 • License/ID: HPP 1234 • Marital Status: Married

16. Next, create the visit • Click on Create Visit at the left of the screen. • Go to the New Encounter Form at the bottom of the screen. • In the Consultation Brief Description box enter Checkup • Click Save to save the encounter.

17. Your screen should look like this:

18. After you’ve saved the encounter, this screen appears.

19. Where do you go to enter his vital signs? That’s right. Click on Vitals.

20. The Vitals section appears. You can scroll down in this section to enter all the information you want.

21. Enter Henry P. Patient’s vitalsand then click Save Form. • VITAL SIGNS: • Height 5’ 10” • Weight 180 • Temperature 98.4 • Pulse 72 • Respirations 18 • Blood pressure 146/78 • O2 saturation 96% on room air

22. The saved Vital Signs appear

23. What if you entered the wrong information? Suppose after you entered 146/78 you realized that you should have entered 140/72? Where do you click on the form to re-enter the data?

24. That’s right. Click on Edit. The Vitals entries reopen, and you can correct your error.

25. The corrected information now appears.

26. You’ve successfully entered the vital signs for your patient. That’s it for this lesson. Remember to log out of OpenEmr.