Y khoa, y dược - Chapter 2: Transitioning to an electronic health record and the need for clinical information standards

Chapter 2Transitioning to an Electronic Health Record and the Need for Clinical Information StandardsElectronic Health Records for Allied Health CareersCover goes here when readyLearning OutcomesAfter studying this chapter, you should be able to:Describe the major strategies for converting paper-based charts to EHR.List the four ways of entering live patient data into EHR.Explain how desktop, laptop, and tablet computers differ.Discuss the advantages of wireless networks in health care.Explain the major difference between locally hosted and ASP hosting models.2Learning OutcomesAfter studying this chapter, you should be able to:Discuss why the adoption of clinical standards is critical to the successful implementation of electronic health records.Describe the difference between clinical vocabularies and classification systems.List four messaging standards used with electronic health records.Describe the significance of the Medicare Prescription Drug and Modernization Act of 2003 in the adoption of clinical standards.3Key Termsapplication service provider (ASP)classification systemsclientsclinical templatesclinical vocabulariesCurrent Procedural Terminology (CPT)content standardsdesktop computerDigital Imaging and Communications in Medicine (DICOM)Healthcare Common Procedures Coding System (HCPCS), Level IIHealth Level Seven (HL&)hybrid conversionsincremental conversionInstitute of Electrical and Electronics Engineers 1073 (IEEE1073)International Classification of Diseases, Ninth Revisioninteroperablelaptop computerlocally hostedLogical Observation Identifiers Names and Codes (LOINC)messaging standards4Key TermsNational Council for Prescription Drug Program (NCPDP)networkoutsourcingpersonal digital assistant (PDA)picture archiving and communication system (PACS)scanningserversmart phonesSystematized Nomenclature of Medicine Clinical Terms (SNOMED-CT)tablet computertotal conversionUnified Medical Language System (UMLS)voice recognitionwired networkwireless networksworkstations5Converting Existing RecordsConversion strategies:Total conversionIncremental conversionHybrid conversion6Entering Live DataMethods:dictation and transcriptionclinical templatesvoice recognitionscanning7Computer RequirementsInput DevicesWorkstationsdesktop computerslaptop computerstablet computerspersonal digital assistants (PDAs)smart phones8Computer RequirementsNetworksserver = “hub” of network; houses data and applicationsclients = computers that access the server over the networkwired network vs. wireless network9Hosting ChoicesLocally Hosted ModelApplication Service Provider ModelBlended or Hybrid Model10The Importance of Clinical StandardsFor shared information to be useful, computer systems must be interoperable No mandatory standards for clinical data exist yet.11Clinical Information StandardsClinical vocabulariesSystematized Nomenclature of Medicine Clinical Terms (SNOMED-CT)Logical Observation Identifiers Names and Codes (LOINC)U.S. National Library of Medicine Unified Medical Language System (UMLS)12Clinical Information StandardsClassification systemsInternational Classification of Diseases, Ninth Revision (ICD-9)International Classification of Diseases, Tenth Revision (ICD-10)Current Procedural Terminology (CPT)Healthcare Common Procedures Coding System (HCPCS), Level II13Clinical Information StandardsMessaging StandardsHealth Level Seven (HL7)Digital Imaging and Communications in Medicine (DICOM) Picture Archiving and Communication System (PACS)National Council for Prescription Drug Program (NCPDP) The Institute of Electrical and Electronics Engineers 1073 (IEEE1073) 14Clinical Information StandardsEHR Content StandardsElectronic Health Record System Functional Model (EHR-S-FM) 15