comp3 unit15b lecture slides

Terminology in Healthcare and Public Health Settings

Electronic Health RecordsLecture b – Definitions and

Concepts in the EHRThis material Comp3_Unit15 was developed by The University of Alabama Birmingham, funded by the Department of Health

and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000023

Definitions and Concepts in the EHRLearning Objectives

• Describe differences between EHR, EMR, and PHR

• Define the functional requirements of an EHR• Identify the purposes of EHR components • Describe methods to ensure data security and

confidentiality

2Health IT Workforce Curriculum Version 3.0/Spring 2012

Terminology in Healthcare and Public Health Settings Electronic Health Records

Lecture b

The Electronic Health RecordCommon acronyms for electronic records for patient dataEHR electronic health record (across the

lifespan)CBMR computer-based medical recordCPR computer-based patient recordEPR electronic patient recordEMR electronic medical recordPHR personal health record



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Electronic Medical Records• Electronic records

– Become repositories of patient data– Reside with individual provider – Provide legal record of encounters

• Ambulatory Users– Physicians– Dentists– Pharmacists– Public Health Clinics– Opticians

• Acute Care Users– Hospitals– Emergency Care Centers– Surgical Centers

Source: (Garets & Davis, 2006)



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Components of anElectronic Medical Record

• Clinical Systems• Pharmacy Systems• Laboratory Systems• Admission/Discharge/Transfer Systems

(ADT)• Billing Systems



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Clinical Systems• Clinical Documentation• Clinical Decision Support (CDS)• Computerized Provider Order Entry

(CPOE)• Bar-Code Medication Administration

(BCMA)• Electronic Medication Administration

Record (eMAR)



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Personal Health Records“The Personal Health Record (PHR) is an

Internet-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those

who need it.”

Source: (Markle, 2003)



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Functions of Personal Health Records

• Information Sharing• Information

Exchange• Information Self-

management

Source (CITL, 2008)



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Personal Health Record Models

• Payor tethered• Provider tethered• Third-Party

tethered



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Moving Toward the EHR

Attributes of the EHR • Data Storage

– Enormous capabilities– Small space

• Accessibility via secure servers– From remote sites– Multiple, authorized users at same time

• Information retrieval– Almost instantaneous



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Attributes of the EHR

• Links the clinician to protocols• Offers customized views• Improves risk management• Provides outcomes assessment• Results in more accurate capture of

financial charges and billing efficiency• Increases patient satisfaction



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Key EHR-Related Terms• Computerized Provider Order Entry

(CPOE)



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(CPOE)• Decision-Support Systems (DSS)

– Clinical Decision Support System (CDS)



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Key EHR-Related Terms• Computerized Provider Order Entry (CPOE)• Decision-Support Systems (DSS)

– Clinical Decision Support System (CDS)• E-prescribing (eRx)

– Use of computer devices to review drug and formularies– Electronic transmission of prescriptions to pharmacies– Integration with clinical decision support

Source: (Office of the National Coordinator, 2012)



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(CPOE)• Decision-Support Systems (DSS)

– Clinical Decision Support System (CDS)• E-prescribing (eRx)• Health Information Exchange (HIE)

– Regional Health Information Organization (RHIO)– Nationwide Health Information Network (NwHIN)



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Data Security and Confidentiality



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Confidentiality and Security• Confidentiality

– Data/information is not available or disclosed to any unauthorized person or process

– Includes paper and electronic records

Sources: (Office for Civil Rights, 2006)



Lecture b

Confidentiality and Security• Confidentiality

– Data/information is not available or disclosed to any unauthorized person or process

– Includes paper and electronic records• Security

– Protects information from unauthorized access or destruction

– Refers to all administrative, physical and technical safeguards that protect patient information

Sources: (Office for Civil Rights, 2006)



Lecture b

Legal Protections

• Health Insurance Portability and Accountability Act (HIPAA)– HIPAA Privacy Rule– HIPAA Security Rule

• Patient Safety Rule• Enforced by Office for Civil Rights

– Department of Health and Human Services

Sources: (Office for Civil Rights, 2006)(Office for Civil Rights, 2008)



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Maintaining Security• Uninterrupted power supply• Back-ups• Mirrored systems• Off-site data storage• Disaster recovery plans



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Security Measures to Maintain Confidentiality

• Authentication



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• Authentication• Audit Trails



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• Authentication• Audit Trails• Firewalls

Source: (Amatayakul, 2009, p 497)



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• Authentication• Audit Trails• Firewalls• Encryption



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Other Measures to Maintain Confidentiality

• Authentication• Audit Trails• Firewalls• Encryption• Confidentiality Statements



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Electronic Health RecordsSummary

• Identify the functions of the health record• Describe the Health Information Technology for

Economic and Clinical Health Act (HITECH) of 2009 and the concept of “meaningful use”

• Describe differences between EHR, EMR, and PHR• Define functional requirements of EHR• Identify the purposes of EHR components • Describe methods to ensure data security and

confidentiality



Lecture b

Electronic Health RecordsReferences – Lecture b

References•Amatayakul MK. Electronic health records: A practical guide for professionals and organizations. Chicago (IL): AHIMA; 2009.•CITL. The value of personal health records. Center for Healthcare Technology Leadership, 2008. Available from:http://tigerphr.pbworks.com/f/CITL_PHR_Report.pdf•Garets D, Davis M. Electronic medical records vs. electronic health records: yes, there is a difference. Chicago (IL): HIMSS Analytics, 2006, p. 2. Available from: http://www.himssanalytics.org/docs/WP_EMR_EHR.pdf•Office for Civil Rights. HIPAA Administrative Simplification; Regulation Text. US Department of Health and Human Services,. 2006 Feb 16. Available from: http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/adminsimpregtext.pdf•Markle. Connecting for Health. A public-private collaborative. The personal health working group. Final report; 2003 Jul 1; New York: Markle Foundation. p. 3.•Office for Civil Rights. The Patient Safety Rule. US Department of Health and Human Services. 2008 Nov 21. Available from: http://www.hhs.gov/ocr/privacy/psa/regulation/rule/index.html•Office of the National Coordinator for Health IT. Health IT terms. [Internet] Available from: http://healthit.hhs.gov/portal/server.pt/community/health_it_hhs_gov__glossary/1256•ONC. Acronyms. Available from: http://healthit.hhs.gov/portal/server.pt/community/health_it_hhs_gov__acronyms/1217

ImagesSlides 7,8,17, 20, 21: Microsoft clip art; Used with permission from Microsoft.



Lecture b

comp3 unit15b lecture slides

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