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

Chapter 1Introduction to Electronic Health RecordsElectronic Health Records for Allied Health CareersCover goes here when ready1-1Learning OutcomesAfter studying this chapter, you should be able to:List three reasons why paper-based medical records are no longer adequate.Discuss the economic pressures forcing changes in the health care system.Describe the role of the government in bringing about changes in the health care system.Explain the differences between electronic medical records, electronic health records, and personal health records.Compare the content of a medical record in ambulatory and acute care settings.1-2Learning OutcomesAfter studying this chapter, you should be able to:List the eight core functions of an electronic health record.Describe the advantages of electronic health records.Explain the issues surrounding the implementation of electronic health records.Explain how electronic health records will affect existing jobs in allied health as well as create new jobs.1-3acute careadverse eventambulatory carecontinuity of careelectronic health record (EHR)electronic medical record (EMR)electronic prescribingevidence-based medicinehealth information exchange (HIE)health information technology (HIT)Health Insurance Portability and Accountability Act of 1996 (HIPAA)medical errormedical recordMedicare Part DMedicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)National Health Information Network (NHIN)pay for performancepersonal health record (PHR)regional health information organization (RHIO)standardsKey Terms1-4A Mandate for ChangeEnormous 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 care1-5Medical ErrorsAdverse 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.1-6Causes of Medical Errorsmisfiled or lost medical recordsmishandled patient requests and messagesinaccurate medical record dataillegible handwritingmislabeled laboratory specimensmedication mistakes1-7Rising Health Care CostsU.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.1-8Coordination of CarePatients 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 information1-9Trends in Technology, the Economy, and Government PolicyWidespread use of health information technology (HIT) could: improve quality of health care prevent medical errors reduce health care costs1-10Advances in TechnologyToday’s technology makes it feasible and practical for physician practices to use computer technology for patient records:speed of data transmissionwireless communicationlower costs1-11Economic PressuresContinuous rising costs for patients, government, physicians, and employers.Administrative costs: paper-based systems have heavy administrative costsMedical Liability Premiums: medical liability insurance premiums at all-time highEmployer-Sponsored Insurance Premiums: rose 87% since 2000; costs threatening businesses1-12Government HIT InitiativesFederal 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 years1-13What is a Medical RecordMedical record: legal and business documentation of all encounters with a health care provider including:medical historyassessment, diagnosis, and treatment planlaboratory test results, x-rays, other test resultslist of medications prescribedsurgical reports (and reports of other procedures)1-14What is a Medical RecordMedical records are used for:supporting clinical decisionsdocumenting services provided for billing purposesdocumenting patient conditions and responses to treatment1-15Some DefinitionsElectronic medical recordElectronic health recordPersonal health record1-16Contents of a Health Recordacute care ambulatory care1-17The Purpose and Use of Health RecordsPrimary PurposeTo assist health care professionals in providing the most effective patient care.1-18The Purpose and Use of Health RecordsSecondary UsesBilling and ReimbursementLegal IssuesQuality ReviewResearchEducationPublic Health and Homeland SecurityCredentialing1-19Core Functions of an Electronic Health Record SystemHealth Information and DataResults ManagementOrder ManagementDecision SupportElectronic Communication and ConnectivityPatient SupportAdministrative ProcessesReporting and Population Management1-20Advantages of Electronic Health RecordsSafetyQualityEfficiencyFuture Cost Reduction1-21Implementation IssuesCostLack of StandardsLearning CurveWorkflow ChangesChanges in the Software MarketPrivacy and Security Risks1-22The Impact of IT on Allied Health CareersOpportunities 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).1-23Certification and Lifelong LearningHealth care requires lifelong learningCertification demonstrates proficiency; easier to find jobs and typically paid moreSome 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)1-24Outlook and SalariesHealth 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.1-25