Transcript The computerization of the practice Grzegorz Margas

Computerization of the practice
Grzegorz Margas, M.D., Ph.D.
Department of Family Medicine
Jagiellonian University Medical College
EHR
Electronic Health Record
“An aggregate electronic record of healthrelated information on an individual that is
created and gathered cumulativaly accros
more than one health organization and is
managed and consulted by licensed
clinicians and staff involved in the
individuals’s health and care.”
National Alliance for Health Information Technology (NAHIT)
Components of EHR
• Health information and data
– Patient demographics
– Patient problem list
– Electronic lists of medication taken by patients
– Clinical notes
– Medical history and follow-up
Components of EHR
• Order-entry management
– Prescriptions
– Laboratory tests
– Radiology tests
– Electronic prescriptions
– Orders sent electronically
Components of EHR
• Results management
– Viewing laboratory results
– Viewing imaging results
• Clinical decision support
– Warning of drug interactions/contraindications
– Out-of-range test levels highlighted
– Reminders regarding screening, vaccinations
Primary Care Doctors’ Use of
Electronic Patient Medical Records
Schoen C et al. The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven
Countries. "A Survey of Primary Care Physicians in Eleven Countries: Perspectives on Care, Costs, and Experiences, 2009."
Health Affairs Web Exclusive 2009 Nov 5; w1171–w1183
Practice Use of IT on a Routine Basis for Core
Tasks: Electronic entry of clinical notes
Schoen C et al. The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven
Countries. "A Survey of Primary Care Physicians in Eleven Countries: Perspectives on Care, Costs, and Experiences, 2009."
Health Affairs Web Exclusive 2009 Nov 5; w1171–w1183
Electronic Medical Record System Access
Practices with Advanced Electronic Health Information
Capacity
Percent of primary care doctors reporting at least 9 of 14
clinical IT functions*
*The 14 functions include: electronic medical records; the ability to prescribe medicine and order tests electronically;
electronic access to test results, Rx alerts, clinical notes; a computerized system for tracking lab tests, guidelines, alerts to
provide patients with test results, preventive/follow-up care reminders; and a computerized list of patients by diagnosis,
medications, and due date for tests or preventive care.
Practices with Advanced Electronic Health Information
Capacity
Percentage of primary care doctors reporting at least 7 of
14 clinical IT functions*
Notes: The 14 Clinical IT functions include: EMR, EMR access to other doctors, outside offices and patients; the routine use of
ordering tests, writing prescriptions, accessing test results, accessing hospital records electronically; using the computer for
reminders, Rx alerts, prompt tests results; diagnoses, medications and patients due for care that are easy to check.
Steps to computerization:
Administrative
1. Billing
2. Word-processing
3. Internal e-mail & non-clinical external
e-mail
4. Appointments
5. Statuatory requirements for data entry
& reporting
Steps to computerization:
Clinical
1.
2.
3.
4.
5.
6.
7.
Prescribing
Decision support (prescribing)
External clinical data capture / remote links
Consultation data
Care protocols
Clinical audit
Patient education