Y khoa, y dược - Chapter 1: An introduction to electronic health records

Chapter 1An Introduction to Electronic Health Records © 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 1 Content1.1 Brief history of electronic health records (EHRs)1.2 History of standards development for the EHR and nursing’s role in their development1.3 Certification bodies for the EHR1.4 Benefits of the EHR1.5 Government involvement in the EHR1.6 Role of nursing informatics in healthcareL.O. 1.1 The EHR HistoryL.O. 1.1 The EHR HistoryImpetus for developmentQuality patient care1960sFirst EMR programsFirst electronic databasesL.O. 1.1 The EHR HistoryTerms and DefinitionsCPR: Computer-Based Patient RecordEMR: Electronic Medical RecordEHR: Electronic Health RecordCCD: Continuity of Care DocumentPHR: Personal Health RecordL.O. 1.1 The EHR HistoryPoint of care documentationModes of Data EntryKeyboardVoice recognitionHandwriting recognitionTemplates and data selectionTouch screensCOWs/WOWsL.O. 1.1 The EHR HistorySecurity and reliabilityLocal area network (LAN)InternetIntranetData encryptionApplication server provider (ASP) L.O. 1.2 Development of EHR StandardsL.O.1.2 Development of EHR StandardsBarriers to EHR adoptionCostOrganizationLack of unified standards, functionality, and interoperabilityL.O.1.2 Development of EHR StandardsIOM’s Committee on Data Standards for Patient Safety – 2003Identified key competenciesBecame foundational benchmark for EHR development and programmingConsolidated Health Informatics (CHI) standards - 2004Enabled agencies to share informationCommon clinical vocabulariesStandard methods of transmissionL.O.1.2 Development of EHR StandardsRole of nursing in standards developmentPromotes standardization to identify nursing’s contribution to patient carePromotes researchPromotes identification of relationships among nursing interventions and outcomesL.O.1.2 Development of EHR StandardsTechnology Informatics Guiding Educational Reform (TIGER) InitiativeGoal to ensure nursing input into the standardization process for EHRsCalls for agreement on the standardized nursing terminology to promote interoperabilityStandardized nursing language examplesNANDA-I, NOC, NICICNPL.O. 1.3 EHR Certification AgenciesL.O. 1.3 EHR Certification AgenciesThe Certification Commission for Health Information Technology (July 2004)Mission: To accelerate the adoption of health information technology by creating an efficient, credible, and sustainable product certification programL.O. 1.3 EHR Certification AgenciesCCHITCreates inspection process for:Ambulatory care EHRs for the office-based healthcare providerInpatient EHRs for hospitals and health systemsNetwork components through which EHRs interoperate and share informationL.O. 1.3 EHR Certification AgenciesOffice of the National Coordinator for Health Information Technology (ONC) - 2004PurposesServe as a resource to the entire health systemSupport the adoption of health information technologyPromote a nationwide health information exchange in order to improve healthcare in the United StatesL.O. 1.4 Benefits of The EHRL.O. 1.4 Benefits of The EHREnhanced accessibility to clinical informationPatient safetyQuality patient careEfficiency and savingsL.O. 1.5 Government Involvement in the EHRL.O. 1.5 Government Involvement in the EHRPresident George W. Bush (2004)Called for universal EHRs by 2014 “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”L.O. 1.5 Government Involvement in the EHRMedicare Improvements for Patients and Providers Act of 2008 (MIPPA)Positive incentives for practitioners who use e-prescribingPenalties for practitioners who do not e-prescribe after 2014SurescriptsNational clearinghouse for e-prescribingL.O. 1.5 Government Involvement in the EHRAmerican Recovery and Reinvestment Act (ARRA) - 2009The Health Information Technology for Economic and Clinical Health (HITECH) Act$20 billion to aid in the development of a healthcare infrastructure and to promote adoption and use of health information technology, including EHRsRequires “meaningful use” of a “certified” EHRProvides bonus/incentive paymentsL.O. 1.6 Nursing InformaticsL.O. 1.6 Nursing InformaticsFlorence Nightingale Recognized the need for standardization of nursing language to facilitate communication and enhance quality careHarriet Werley first provided nursing input for computer use in the healthcare arena in the 1950s1970s: Nursing applications for computers began to be developedL.O. 1.6 Nursing Informatics1973North American Nursing Diagnosis Association (NANDA)Developed initial set of nursing diagnoses1980sDevelopment of personal computersNursing informatics courses1994Nursing informatics recognized as nursing specialty Scope and standards of nursing informatics practice developedL.O. 1.6 Nursing InformaticsNursing informatics Supports quality of nursing decisions by enhancing access to nursing knowledge and patient informationPromotes development and use of tools compiled from a variety of sciencesAssists with managing and communicating information and knowledge between healthcare team membersPromotes access to current evidence-based nursing practice