Transcript Lesson 1 Getting Started in PowerPoint

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Electronic Health
Records for Allied
Health Careers
Chapter 1
Introduction to
Electronic Health
Records
McGraw-Hill
Copyright © 2009 by The McGraw-Hill Companies, Inc. All Rights Reserved.
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Learning Outcomes
After studying this chapter, you should be able to:
1. List three reasons why paper-based medical records are
no longer adequate.
2. Discuss the economic pressures forcing changes in the
health care system.
3. Describe the role of the government in bringing about
changes in the health care system.
4. Explain the differences between electronic medical
records, electronic health records, and personal health
records.
5. Compare the content of a medical record in ambulatory
and acute care settings.
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Learning Outcomes
After studying this chapter, you should be able to:
6. List the eight core functions of an electronic health record.
7. Describe the advantages of electronic health records.
8. Explain the issues surrounding the implementation of
electronic health records.
9. Explain how electronic health records will affect existing
jobs in allied health as well as create new jobs.
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Key Terms
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acute care
adverse event
ambulatory care
continuity of care
electronic health record (EHR)
electronic medical record (EMR)
electronic prescribing
evidence-based medicine
health information exchange
(HIE)
• health information technology
(HIT)
• Health Insurance Portability and
Accountability Act of 1996
(HIPAA)
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medical error
medical record
Medicare Part D
Medicare Prescription Drug,
Improvement, and
Modernization Act of 2003
(MMA)
National Health Information
Network (NHIN)
pay for performance
personal health record (PHR)
regional health information
organization (RHIO)
standards
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A Mandate for Change
Enormous change in health care field shifting
from paper-based records to electronic record
systems.
Why?
• increase in medical errors
• rising health care costs
• need for coordination of care
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Medical Errors
Adverse event: patient harm resulting from treatment by
health care system, not health condition of patient.
Not all adverse events are errors (e.g., side effects of
medications).
Medical error: preventable adverse event (e.g., dispensing
incorrect dosage of medication, surgery performed on wrong
site).
Medical errors = 8th leading cause of death in U.S.
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Causes of Medical Errors
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misfiled or lost medical records
mishandled patient requests and messages
inaccurate medical record data
illegible handwriting
mislabeled laboratory specimens
medication mistakes
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Rising Health Care Costs
• U.S. spends approximately $2 trillion a year on
health care.
• About 31% for administration, not direct patient
care.
• Tremendous amount spent on treatments that are
ineffective, duplicate another procedure, or are
inappropriate.
• U.S. adults benefit from treatment only about half
the time.
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Coordination of Care
• Patients receive treatment from multiple medical
professionals at various facilities.
• Providers maintain own paper-based medical
records and do not have access to records of
other providers treating same patients. As a result,
they often do not have complete information
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Trends in Technology, the Economy, and
Government Policy
• Widespread use of health information technology
(HIT) could:
– improve quality of health care
– prevent medical errors
– reduce health care costs
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Advances in Technology
• Today’s technology makes it feasible and practical
for physician practices to use computer
technology for patient records:
– speed of data transmission
– wireless communication
– lower costs
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Economic Pressures
• Continuous rising costs for patients, government,
physicians, and employers.
– Administrative costs: paper-based systems have
heavy administrative costs
– Medical Liability Premiums: medical liability insurance
premiums at all-time high
– Employer-Sponsored Insurance Premiums: rose
87% since 2000; costs threatening businesses
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Government HIT Initiatives
• Federal government leading push for health
information technology.
– Health Insurance Portability and Accountability Act of
1996 (HIPAA)
– Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA)
– In 2004, President Bush set goal of electronic health
records within 10 years
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What is a Medical Record
• Medical record: legal and business documentation
of all encounters with a health care provider
including:
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medical history
assessment, diagnosis, and treatment plan
laboratory test results, x-rays, other test results
list of medications prescribed
surgical reports (and reports of other procedures)
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What is a Medical Record
• Medical records are used for:
– supporting clinical decisions
– documenting services provided for billing purposes
– documenting patient conditions and responses to
treatment
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Some Definitions
• Electronic medical record
• Electronic health record
• Personal health record
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Contents of a Health Record
– acute care
– ambulatory care
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The Purpose and Use of Health Records
• Primary Purpose
– To assist health care professionals in providing the
most effective patient care.
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The Purpose and Use of Health Records
• Secondary Uses
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Billing and Reimbursement
Legal Issues
Quality Review
Research
Education
Public Health and Homeland Security
Credentialing
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Core Functions of an Electronic Health
Record System
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Health Information and Data
Results Management
Order Management
Decision Support
Electronic Communication and Connectivity
Patient Support
Administrative Processes
Reporting and Population Management
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Advantages of Electronic Health Records
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Safety
Quality
Efficiency
Future Cost Reduction
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Implementation Issues
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Cost
Lack of Standards
Learning Curve
Workflow Changes
Changes in the Software Market
Privacy and Security Risks
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The Impact of IT on Allied Health Careers
• Opportunities for employment in many
environments (e.g., physician offices, hospitals,
insurance carriers, pharmaceutical companies)
• Allied health graduates will need skills in HIT;
demand for these skills will exceed the supply.
• HIT will create new careers (e.g., clinical analyst,
health information technician, information privacy
coordinator).
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Certification and Lifelong Learning
• Health care requires lifelong learning
• Certification demonstrates proficiency; easier to find
jobs and typically paid more
• Some health information technology certifications:
– Registered Health Information Technician (RHIT)
and Registered Health Information Administrator
(RHIA) offered by American Health Information
Management Association (AHIMA)
– Medical Coding certifications: offered by AHIMA
and American Academy of Professional Coders
(AAPC)
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Outlook and Salaries
• Health care field remains one of fastest growing
segments of economy.
• As population ages, health care needs increase
and new jobs created.
• Salaries dependent on factors such as location,
size of organization, education and experience of
individual, etc.