Transcript mo 250: medical records: electronic health record management

UNIT 5 SEMINAR
 According
to your text, in an acute care
setting, an electronic health record
integrates electronic data from multiple
clinical systems to provide a single access
point for information about a patient’s
health care. These systems commonly
include data for ancillary services such as
laboratory, radiology, and pharmacy systems,
among others.
 1.
Discuss the functions of an EHR in an
acute care hospital.
 Functions
of EHR in an acute care hospital:
 Financial information
 Laboratory information systems
 Pharmacy information systems
 Picture archiving and communication systems
 Radiology information systems
 Clinical information systems
 2.
Discuss the benefits of a hospital EHR.
 Benefits
of hospital EHR:
 Immediate access to complete, up-to-date
information about patients, including
progress notes, results of laboratory tests
and imaging studies, medication
administration, and responses to treatment
 Decreased turnaround times for medication
delivery and completion of diagnostic tests
due to electronic delivery of orders and
results.
 Benefits
of EHR (cont.):
 Increased efficiency by standardizing work
processes and by integrating information
from different departments.
 The main benefit of EHRs, however, is not
their ability to provide fast access to current
and complete patients records.
 The most significant contribution of EHRs is
that they offer decision-support tools that
help physicians make diagnosis and
treatment decisions that provide patients
with the safest, most effective care.
 3.
How is clinical documentation used in an
inpatient setting?
Use of clinical documentation in a inpatient
setting:
 Assist in patient care planning and continuity of
care
 Provide evidence of the course of the patient’s
care and treatment during the hospital stay
 Facilitate communication among members of the
patient care team

Use of clinical documentation in a inpatient
setting:
 Serve as a legal record to protect the interests
of the patient, the hospital , and the clinician
 Supply data for research purposes
 Supply data for utilization review and quality
improvement analysis and reporting
 Providing information that enables coders to
determine the appropriate diagnosis and
procedure codes to substantiate patient billing.

 4.
What are the advantages of CPOE
(computerized physician order entry)?
 Advantages
of CPOE:
 Provides alerts that warn against the
possibility of drug interactions, allergies,
overdoses, or other problems.
 Provides accurate, up-to-date information on
new medications, procedures, and research
 Improves communication among team
members
 Provides physicians with access to decisionsupport tools at the point-of-care
 Advantages
of CPOE:
 Reduces the amount of time it takes to fill
physician orders
 Eliminates the change of an order being
misplaced or lost
 Eliminates errors resulting from illegible
handwriting
 Enables orders to be entered from any
location with computer access in the hospital
or off-site
 Advantages
of CPOE:
 Provides easier access to data for reporting
and quality assessment purposes
 Reduces costs by improving efficiency,
eliminating duplicate tests, and reducing the
number of lawsuits due to medication errors.
 5.
How does decision support tools improve
the quality of patient care?
 Q5A:
Decision support tools allow physicians
to select medications, diagnostic tests and
treatments which results in improved quality
of care and patient outcomes.
 6.
Discuss how the combination of the CPOE
and the E-MAR can assist in reducing errors.
 Q6A:
CPOE eliminates errors that can occur
as a result of illegible handwriting by
enabling physicians to enter patient orders
using a computer. When a physician orders a
medication using CPOE, the order is
automatically entered in the electronic
medical administration records. From that
point on, the medication order and its
administration are tracked by computer using
barcode technology.
 7.
What are the advantages of electronic
results reporting over traditional paperbased reporting systems?
Q7A: Advantages of electronic results
reporting:
 Faster turnaround time: there is minimal delay
between the time the test is finished and the
availability of results. Results can be accessed
from any computer with network access.
 Faster diagnosis and treatment: once clinicians
are alerted that results are available, they can
review the results and consider how that
information affects the possible diagnosis.

 Q7A:
Advantages of electronic results
reporting:
 Efficient
consultations: more than one
physician can view the images at the sample
time, even if the physicians are not in the
same location.
 Faster medication administration: the
laboratory test results for hospitalized
patients are available more quickly, which
makes it possible for patients to receive their
medication sooner.
Q7A: Advantages of electronic results
reporting:
 Fewer duplicate tests: since there is a
computerized record of every test ordered
during a patient’s hospital stay, providers will
see that a test has already been performed
before unknowingly ordering a duplicate test.
 Enhanced analysis: results from lab tests such
as glucose levels or cholesterol levels can be
viewed in graphical format, making it easier to
spot trends in results over time.


Q7A: Advantages of electronic results
reporting:
 Easier
retrieval: since images and results are
stored on a computer, they are easy to locate
and review when necessary.
 Sanderson,
S.M. (2009). Electronic health
records for allied health careers: New York,
NY: McGraw-Hill.